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Literature review, alive program, implications for school social work practice.

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Trauma and Early Adolescent Development: Case Examples from a Trauma-Informed Public Health Middle School Program

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Jason Scott Frydman, Christine Mayor, Trauma and Early Adolescent Development: Case Examples from a Trauma-Informed Public Health Middle School Program, Children & Schools , Volume 39, Issue 4, October 2017, Pages 238–247, https://doi.org/10.1093/cs/cdx017

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Middle-school-age children are faced with a variety of developmental tasks, including the beginning phases of individuation from the family, building peer groups, social and emotional transitions, and cognitive shifts associated with the maturation process. This article summarizes how traumatic events impair and complicate these developmental tasks, which can lead to disruptive behaviors in the school setting. Following the call by Walkley and Cox for more attention to be given to trauma-informed schools, this article provides detailed information about the Animating Learning by Integrating and Validating Experience program: a school-based, trauma-informed intervention for middle school students. This public health model uses psychoeducation, cognitive differentiation, and brief stress reduction counseling sessions to facilitate socioemotional development and academic progress. Case examples from the authors’ clinical work in the New Haven, Connecticut, urban public school system are provided.

Within the U.S. school system there is growing awareness of how traumatic experience negatively affects early adolescent development and functioning ( Chanmugam & Teasley, 2014 ; Perfect, Turley, Carlson, Yohannan, & Gilles, 2016 ; Porche, Costello, & Rosen-Reynoso, 2016 ; Sibinga, Webb, Ghazarian, & Ellen, 2016 ; Turner, Shattuck, Finkelhor, & Hamby, 2017 ; Woodbridge et al., 2016 ). The manifested trauma symptoms of these students have been widely documented and include self-isolation, aggression, and attentional deficit and hyperactivity, producing individual and schoolwide difficulties ( Cook et al., 2005 ; Iachini, Petiwala, & DeHart, 2016 ; Oehlberg, 2008 ; Sajnani, Jewers-Dailley, Brillante, Puglisi, & Johnson, 2014 ). To address this vulnerability, school social workers should be aware of public health models promoting prevention, data-driven investigation, and broad-based trauma interventions ( Chafouleas, Johnson, Overstreet, & Santos, 2016 ; Johnson, 2012 ; Moon, Williford, & Mendenhall, 2017 ; Overstreet & Chafouleas, 2016 ; Overstreet & Matthews, 2011 ). Without comprehensive and effective interventions in the school setting, seminal adolescent developmental tasks are at risk.

This article follows the twofold call by Walkley and Cox (2013) for school social workers to develop a heightened awareness of trauma exposure's impact on childhood development and to highlight trauma-informed practices in the school setting. In reference to the former, this article will not focus on the general impact of toxic stress, or chronic trauma, on early adolescents in the school setting, as this work has been widely documented. Rather, it begins with a synthesis of how exposure to trauma impairs early adolescent developmental tasks. As to the latter, we will outline and discuss the Animating Learning by Integrating and Validating Experience (ALIVE) program, a school-based, trauma-informed intervention that is grounded in a public health framework. The model uses psychoeducation, cognitive differentiation, and brief stress reduction sessions to promote socioemotional development and academic progress. We present two clinical cases as examples of trauma-informed, school-based practice, and then apply their experience working in an urban, public middle school to explicate intervention theory and practice for school social workers.

Impact of Trauma Exposure on Early Adolescent Developmental Tasks

Social development.

Impact of Trauma on Early Adolescent Development

Traumatic experiences may create difficulty with developing and differentiating another person's point of view (that is, mentalization) due to the formation of rigid cognitive schemas that dictate notions of self, others, and the external world ( Frydman & McLellan, 2014 ). For early adolescents, the ability to diversify a single perspective with complexity is central to modulating affective experience. Without the capacity to diversify one's perspective, there is often difficulty differentiating between a nonthreatening current situation that may harbor reminders of the traumatic experience and actual traumatic events. Incumbent on the school social worker is the need to help students understand how these conflicts may trigger a memory of harm, abandonment, or loss and how to differentiate these past memories from the present conflict. This is of particular concern when these reactions are conflated with more common middle school behaviors such as withdrawing, blaming, criticizing, and gossiping ( Card, Stucky, Sawalani, & Little, 2008 ).

Encouraging cognitive discrimination is particularly meaningful given that the second social developmental task for early adolescents is the re-orientation of their primary relationships with family toward peers ( Henderson & Thompson, 2010 ). This shift may become complicated for students facing traumatic stress, resulting in a stunted movement away from familiar connections or a displacement of dysfunctional family relationships onto peers. For example, in the former, a student who has witnessed and intervened to protect his mother from severe domestic violence might believe he needs to sacrifice himself and be available to his mother, forgoing typical peer interactions. In the latter, a student who was beaten when a loud, intoxicated family member came home might become enraged, anxious, or anticipate violence when other students raise their voices.

Cognitive Development and Emotional Regulation

During normative early adolescent development, the prefrontal cortex undergoes maturational shifts in cognitive and emotional functioning, including increased impulse control and affect regulation ( Wigfield, Lutz, & Wagner, 2005 ). However, these developmental tasks can be negatively affected by chronic exposure to traumatic events. Stressful situations often evoke a fear response, which inhibits executive functioning and commonly results in a fight-flight-freeze reaction. If a student does not possess strong anxiety management skills to cope with reminders of the trauma, the student is prone to further emotional dysregulation, lowered frustration tolerance, and increased behavioral problems and depressive symptoms ( Iachini et al., 2016 ; Saltzman, Steinberg, Layne, Aisenberg, & Pynoos, 2001 ).

Typical cognitive development in early adolescence is defined by the ambiguity of a transitional stage between childhood remedial capacity and adult refinement ( Casey & Caudle, 2013 ; Van Duijvenvoorde & Crone, 2013 ). Casey and Caudle (2013) found that although adolescents performed equally as well as, if not better than, adults on a self-control task when no emotional information was present, the introduction of affectively laden social cues resulted in diminished performance. The developmental challenge for the early adolescent then is to facilitate the coordination of this ever-shifting dynamic between cognition and affect. Although early adolescents may display efficient and logically informed behaviors, they may struggle to sustain these behaviors, especially in the presence of emotional stimuli ( Casey & Caudle, 2013 ; Van Duijvenvoorde & Crone, 2013 ). Because trauma often evokes an emotional response ( Johnson & Lubin, 2015 ), these findings insinuate that those early adolescents who are chronically exposed will have ongoing regulation difficulties. Further empirical findings considering the cognitive effects of trauma exposure on the adolescent brain have highlighted detriments in working memory, inhibition, memory, and planning ability ( Moradi, Neshat Doost, Taghavi, Yule, & Dalgleish, 1999 ).

Using a Public Health Framework for School-Based, Trauma-Informed Services

The need for a more informed and comprehensive approach to addressing trauma within the schools has been widely articulated ( Chafouleas et al., 2016 ; Durlak, Weissberg, Dymnicki, Taylor, & Schellinger, 2011 ; Jaycox, Kataoka, Stein, Langley, & Wong, 2012 ; Overstreet & Chafouleas, 2016 ; Perry & Daniels, 2016 ). Overstreet and Matthews (2011) suggested that using a public health model to address trauma in schools will promote prevention, early identification, and data-driven investigation and yield broad-based intervention on a policy and communitywide level. A public health approach focuses on developing interventions that address the underlying causal processes that lead to social, emotional, and cognitive maladjustment. Opening the dialogue to the entire student body, as well as teachers and administrators, promotes inclusion and provides a comprehensive foundation for psychoeducation, assessment, and prevention.

ALIVE: A Comprehensive Public Health Intervention for Middle School Students

Note: ALIVE = Animating Learning by Integrating and Validating Experience.

Psychoeducation

The classroom is a place traditionally dedicated to academic pursuits; however, it also serves as an indicator of trauma's impact on cognitive functioning evidenced by poor grades, behavioral dysregulation, and social turbulence. ALIVE practitioners conduct weekly trauma-focused dialogues in the classroom to normalize conversations addressing trauma, to recruit and rehearse more adaptive cognitive skills, and to engage in an insight-oriented process ( Sajnani et al., 2014 ).

Using a parable as a projective tool for identification and connection, the model helps students tolerate direct discussions about adverse experiences. The ALIVE practitioner begins each academic year by telling the parable of a woman named Miss Kendra, who struggled to cope with the loss of her 10-year-old child. Miss Kendra is able to make meaning out of her loss by providing support for schoolchildren who have encountered adverse experiences, serving as a reminder of the strength it takes to press forward after a traumatic event. The intention of this parable is to establish a metaphor for survival and strength to fortify the coping skills already held by trauma-exposed middle school students. Furthermore, Miss Kendra offers early adolescents an opportunity to project their own needs onto the story, creating a personalized figure who embodies support for socioemotional growth.

Following this parable, the students’ attention is directed toward Miss Kendra's List, a poster that is permanently displayed in the classroom. The list includes a series of statements against adolescent maltreatment, comprehensively identifying various traumatic stressors such as witnessing domestic violence; being physically, verbally, or sexually abused; and losing a loved one to neighborhood violence. The second section of the list identifies what may happen to early adolescents when they experience trauma from emotional, social, and academic perspectives. The practitioner uses this list to provide information about the nature and impact of trauma, while modeling for students and staff the ability to discuss difficult experiences as a way of connecting with one another with a sense of hope and strength.

Furthermore, creating a dialogue about these issues with early adolescents facilitates a culture of acceptance, tolerance, and understanding, engendering empathy and identification among students. This fostering of interpersonal connection provides a reparative and differentiated experience to trauma ( Hartling & Sparks, 2008 ; Henderson & Thompson, 2010 ; Johnson & Lubin, 2015 ) and is particularly important given the peer-focused developmental tasks of early adolescence. The positive feelings evoked through classroom-based conversation are predicated on empathic identification among the students and an accompanying sense of relief in understanding the scope of trauma's impact. Furthermore, the consistent appearance of and engagement by the ALIVE practitioner, and the continual presence of Miss Kendra's list, effectively counters traumatically informed expectations of abandonment and loss while aligning with a public health model that attends to the impact of trauma on a regular, systemwide basis.

Participatory and Somatic Indicators for Informal Assessment during the Psychoeducation Component of the ALIVE Intervention

Notes: ALIVE = Animating Learning by Integrating and Validating Experience. Examples are derived from authors’ clinical experiences.

In addition to behavioral symptoms, the content of conversation is considered. All practitioners in the ALIVE program are mandated reporters, and any content presented that meets criteria for suspicion of child maltreatment is brought to the attention of the school leadership and ALIVE director. According to Johnson (2012) , reports of child maltreatment to the Connecticut Department of Child and Family Services have actually decreased in the schools where the program has been implemented “because [the ALIVE program is] catching problems well before they have risen to the severity that would require reporting” (p. 17).

Case Example 1

The following demonstrates a middle school classroom psychoeducation session and assessment facilitated by an ALIVE practitioner (the first author). All names and identifying characteristics have been changed to protect confidentiality.

Ms. Skylar's seventh grade class comprised many students living in low-income housing or in a neighborhood characterized by high poverty and frequent criminal activity. During the second week of school, I introduced myself as a practitioner who was here to speak directly about difficult experiences and how these instances might affect academic functioning and students’ thoughts about themselves, others, and their environment.

After sharing the Miss Kendra parable and list, I invited the students to share their thoughts about Miss Kendra and her journey. Tyreke began the conversation by wondering whether Miss Kendra lost her child to gun violence, exploring the connection between the list and the story and his own frequent exposure to neighborhood shootings. To transition a singular connection to a communal one, I asked the students if this was a shared experience. The majority of students nodded in agreement. I referred the students back to the list and asked them to identify how someone's school functioning or mood may be affected by ongoing neighborhood gun violence. While the students read the list, I actively monitored reactions and scanned for inattention and active avoidance. Performing both active facilitation of discussion and monitoring students’ reactions is critical in accomplishing the goals of providing quality psychoeducation and identifying at-risk students for intervention.

After inspection, Cleo remarked that, contrary to a listed outcome on Miss Kendra's list, neighborhood gun violence does not make him feel lonely; rather, he “doesn't care about it.” Slumped down in his chair, head resting on his crossed arms on the desk in front of him, Cleo's body language suggested a somatized disengagement. I invited other students to share their individual reactions. Tyreke agreed that loneliness is not the identified affective experience; rather, for him, it's feeling “mad or scared.” Immediately, Greg concurred, expressing that “it makes me more mad, and I think about my family.”

Encouraging a variety of viewpoints, I stated, “It sounds like it might make you mad, scared, and may even bring up thoughts about your family. I wonder why people have different reactions?” Doing so moved the conversation into a phase of deeper reflection, simultaneously honoring the students’ voiced experience while encouraging critical thinking. A number of students responded by offering connections to their lives, some indicating they had difficulty identifying feelings. I reflected back, “Sometimes people feel something, but can't really put their finger on it, and sometimes they know exactly how they feel or who it makes them think about.”

I followed with a question: “How do you think it affects your schoolwork or feelings when you're in school?” Greg and Natalia both offered that sometimes difficult or confusing thoughts can consume their whole day, even while in class. Sharon began to offer a related comment when Cleo interrupted by speaking at an elevated volume to his desk partner, Tyreke. The two began to snicker and pull focus. By the time they gained the class's full attention, Cleo was openly laughing and pushing his chair back, stating, “No way! She DID!? That's crazy”; he began to stand up, enlisting Tyreke in the process. While this disruption may be viewed as a challenge to the discussion, it is essential to understand all behavior in context of the session's trauma content. Therefore, Cleo's outburst was interpreted as a potential avenue for further exploration of the topic regarding gun violence and difficulties concentrating. In turn, I posed this question to the class: “Should we talk about this stuff? I wonder if sometimes people have a hard time tolerating it. Can anybody think of why it might be important? Sharon, I think you were saying something about this.” While Sharon continued to share, Cleo and Tyreke gradually shifted their attention back to the conversation. I noted the importance of an individual follow-up with Cleo.

Natalia jumped back in the conversation, stating, “I think we talk about stuff like this so we know about it and can help people with it.” I checked in with the rest of the class about this strategy for coping with the impact of trauma exposure on school functioning: “So it sounds like these thoughts have a pretty big impact on your day. If that's the case, how do you feel less worried or mad or scared?” Marta quickly responded, “You could talk to someone.” I responded, “Part of my job here is to be a person to talk to one-on-one about these things. Hopefully, it will help you feel better to get some of that stuff off your chest.” The students nodded, acknowledging that I would return to discuss other items on the list and that there would be opportunities to check in with me individually if needed.

On reflection, Cleo's disruption in the discussion may be attributed to his personal difficulty emotionally managing intrusive thoughts while in school. This clinical assumption was not explicitly named in the moment, but was noted as information for further individual follow-up. When I met individually with Cleo, Cleo reported that his cousin had been shot a month ago, causing him to feel confused and angry. I continued to work with him individually, which resulted in a reduction of behavioral disruptions in the classroom.

In the preceding case example, the practitioner performed a variety of public health tasks. Foremost was the introduction of how traumatic experience may affect individuals and their relationships with others and their role as a student. Second, the practitioner used Miss Kendra and her list as a foundational mechanism to ground the conversation and serve as a reference point for the students’ experience. Finally, the practitioner actively monitored individual responses to the material as a means of identifying students who may require more support. All three of these processes are supported within the public health framework as a means toward assessment and early intervention for early adolescents who may be exposed to trauma.

Individualized Stress Reduction Intervention

Students are seen for individualized support if they display significant externalizing or internalizing trauma-related behavior. Students are either self-referred; referred by a teacher, administrator, or staff member; or identified by an ALIVE practitioner. Following the principle of immediate engagement based on emergent traumatic material, individual sessions are brief, lasting only 15 to 20 minutes. Using trauma-centered psychotherapy ( Johnson & Lubin, 2015 ), a brief inquiry addressing the current problem is conducted to identify the trauma trigger connected to the original harm, fostering cognitive discrimination. Conversation about the adverse experience proceeds in a calm, direct way focusing on differentiating between intrusive memories and the current situation at school ( Sajnani et al., 2014 ). Once the student exhibits greater emotional regulation, the ALIVE practitioner returns the student to the classroom in a timely manner and may provide either brief follow-up sessions for preventive purposes or, when appropriate, refer the student to more regular, clinical support in or out of the school.

Case Example 2

The following case example is representative of the brief, immediate, and open engagement with traumatic material and encouragement of cognitive discrimination. This intervention was conducted with a sixth grade student, Jacob (name and identifying information changed to ensure confidentiality), by an ALIVE practitioner (the second author).

I found Jacob in the hallway violently shaking a trash can, kicking the classroom door, and slamming his hands into the wall and locker. His teacher was standing at the door, distressed, stating, “Jacob, you need to calm down and go to the office, or I'm calling home!” Jacob yelled, “It's not fair, it was him, not me! I'm gonna fight him!” As I approached, I asked what was making him so angry, but he said, “I don't want to talk about it.” Rather than asking him to calm down or stop slamming objects, I instead approached the potential memory agitating him, stating, “My guess is that you are angry for a very good reason.” Upon this simple connection, he sighed and stopped kicking the trash can and slamming the wall. Jacob continued to demonstrate physical and emotional activation, pacing the hallway and making a fist; however, he was able to recount putting trash in the trash can when a peer pushed him from behind, causing him to yell. Jacob explained that his teacher heard him yelling and scolded him, making him more mad. Jacob stated, “She didn't even know what happened and she blamed me. I was trying to help her by taking out all of our breakfast trash. It's not fair.”

The ALIVE practitioner listens to students’ complaints with two ears, one for the current complaint and one for affect-laden details that may be connected to the original trauma to inquire further into the source of the trigger. Affect-laden details in case example 2 include Jacob's anger about being blamed (rather than toward the student who pushed him), his original intention to help, and his repetition of the phrase “it's not fair.” Having met with Jacob previously, I was aware that his mother suffers from physical and mental health difficulties. When his mother is not doing well, he (as the parentified child) typically takes care of the household, performing tasks like cooking, cleaning, and helping with his two younger siblings and older autistic brother. In the past, Jacob has discussed both idealizing his mother and holding internalized anger that he rarely expresses at home because he worries his anger will “make her sick.”

I know sometimes when you are trying to help mom, there are times she gets upset with you for not doing it exactly right, or when your brothers start something, she will blame you. What just happened sounds familiar—you were trying to help your teacher by taking out the garbage when another student pushed you, and then you were the one who got in trouble.

Jacob nodded his head and explained that he was simply trying to help.

I moved into a more detailed inquiry, to see if there was a more recent stressor I was unaware of. When I asked how his mother was doing this week, Jacob revealed that his mother's health had deteriorated and his aunt had temporarily moved in. Jacob told me that he had been yelled at by both his mother and his aunt that morning, when his younger brother was not ready for school. I asked, “I wonder if when the student pushed you it reminded you of getting into trouble because of something your little brother did this morning?” Jacob nodded. The displacement was clear: He had been reminded of this incident at school and was reacting with anger based on his family dynamic, and worries connected to his mother.

My guess is that you were a mix of both worried and angry by the time you got to school, with what's happening at home. You were trying to help with the garbage like you try to help mom when she isn't doing well, so when you got pushed it was like your brother being late, and then when you got blamed by your teacher it was like your mom and aunt yelling, and it all came flooding back in. The problem is, you let out those feelings here. Even though there are some similar things, it's not totally the same, right? Can you tell me what is different?

Jacob nodded and was able to explain that the other student was probably just playing and did not mean to get him into trouble, and that his teacher did not usually yell at him or make him worried. Highlighting this important differentiation, I replied, “Right—and fighting the student or yelling at the teacher isn't going to solve this, but more importantly, it isn't going to make your mom better or have your family go any easier on you either.” Jacob stated that he knew this was true.

I reassured Jacob that I could help him let out those feelings of worry and anger connected to home so they did not explode out at school and planned to meet again. Jacob confirmed that he was willing to do that. He was able to return to the classroom without incident, with the entire intervention lasting less than 15 minutes.

In case example 2, the practitioner was available for an immediate engagement with disturbing behaviors as they were happening by listening for similarities between the current incident and traumatic stressors; asking for specific details to more effectively help Jacob understand how he was being triggered in school; providing psychoeducation about how these two events had become confused and aiding him in cognitively differentiating between the two; and, last, offering to provide further support to reduce future incidents.

Germane to the practice of school social work is the ability to work flexibly within a public health model to attend to trauma within the school setting. First, we suggest that a primary implication for school social workers is not to wait for explicit problems related to known traumatic experiences to emerge before addressing trauma in the school, but, rather, to follow a model of prevention-assessment-intervention. School social workers are in a unique position within the school system to disseminate trauma-informed material to both students and staff in a preventive capacity. Facilitating this implementation will help to establish a tone and sharpened focus within the school community, norming the process of articulating and engaging with traumatic material. In the aforementioned classroom case example, we have provided a sample of how school social workers might work with entire classrooms on a preventive basis regarding trauma, rather than waiting for individual referrals.

Second, in addition to functional behavior assessments and behavior intervention plans, school social workers maintain a keen eye for qualitative behavioral assessment ( National Association of Social Workers, 2012 ). Using this skill set within a trauma-informed model will help to identify those students in need who may be reluctant or resistant to explicitly ask for help. As called for by Walkley and Cox (2013) , we suggest that using the information presented in Table 1 will help school social workers understand, identify, and assess the impact of trauma on early adolescent developmental tasks. If school social workers engage on a classroom level in trauma psychoeducation and conversations, the information in Table 3 may assist with assessment of children and provide a basis for checking in individually with students as warranted.

Third, school social workers are well positioned to provide individual targeted, trauma-informed interventions based on previous knowledge of individual trauma and through widespread assessment ( Walkley & Cox, 2013 ). The individual case example provides one way of immediately engaging with students who are demonstrating trauma-based behaviors. In this model, school social workers engage in a brief inquiry addressing the current trauma to identify the trauma trigger, discuss the adverse experience in a calm but direct way, and help to differentiate between intrusive memories and the current situation at school. For this latter component, the focus is on cognitive discrimination and emotional regulation so that students can reengage in the classroom within a short time frame.

Fourth, given social work's roots in collaboration and community work, school social workers are encouraged to use a systems-based approach in partnering with allied practitioners and institutions ( D'Agostino, 2013 ), thus supporting the public health tenet of establishing and maintaining a link to the wider community. This may include referring students to regular clinical support in or out of the school. Although the implementation of a trauma-informed program will vary across schools, we suggest that school social workers have the capacity to use a public health school intervention model to ecologically address the psychosocial and behavioral issues stemming from trauma exposure.

As increasing attention is being given to adverse childhood experiences, a tiered approach that uses a public health framework in the schools is necessitated. Nevertheless, there are some limitations to this approach. First, although the interventions outlined here are rooted in prevention and early intervention, there are times when formal, intensive treatment outside of the school setting is warranted. Second, the ALIVE program has primarily been implemented by ALIVE practitioners; the results from piloting this public health framework in other school settings with existing school personnel, such as school social workers, will be necessary before widespread replication.

The public health framework of prevention-assessment-intervention promotes continual engagement with middle school students’ chronic exposure to traumatic stress. There is a need to provide both broad-based and individualized support that seeks to comprehensively ameliorate the social, emotional, and cognitive consequences on early adolescent developmental milestones associated with traumatic experiences. We contend that school social workers are well positioned to address this critical public health issue through proactive and widespread psychoeducation and assessment in the schools, and we have provided case examples to demonstrate one model of doing this work within the school day. We hope that this article inspires future writing about how school social workers individually and systemically address trauma in the school system. In alignment with Walkley and Cox (2013) , we encourage others to highlight their practice in incorporating trauma-informed, school-based programming in an effort to increase awareness of effective interventions.

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Woodbridge , M. W. , Sumi , W. C. , Thornton , S. P. , Fabrikant , N. , Rouspil , K. M. , Langley , A. K. , & Kataoka , S. H. ( 2016 ). Screening for trauma in early adolescence: Findings from a diverse school district . School Mental Health, 8 ( 1 ), 89 – 105 .

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Children and Families Policy Research Unit

NIHR Children and Families Policy Research Unit

Case Study: Adolescence

Helping young people say 'no': the prevalence of risk-taking behaviour and what works to reduce it.

How many adolescents smoke, drink and take drugs and what kind of interventions work best to stop them?

Adolescent years are a notoriously challenging time, as children go through the biggest changes since their first year of life. It's this life stage that presents the greatest risk to future health, with damaging habits most often picked up between the ages of 11 and 19.

Research under the adolescent theme has examined the trends in health risk behaviours and reviewed interventions designed to prevent them, in order to inform UK health policy for this susceptible group.

Key Points:

• Two studies looked at trends in risky behaviours in adolescents and interventions designed to prevent them
• Smoking, drinking and drug use have individually declined, but a core of young people remain who engage in all three
• School-based interventions designed to empower young people to say 'no' have proved most effective at reducing multiple harmful behaviours

This case study is for the  Adolescence  theme.

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• Helping young people say no
• Cutting the risk
• Mental health in children
• Type 2 diabetes in children
• Family finances and disability
• Stories from data and young people
• Growing up happy in England

Our Case Studies

We have complied a series of publications and case studies to illustrate the type of projects we work on and how we support child health policy-making in England

• The Healthy Child
• Healthcare provision
• Mental health
• Adolescence
• Long-term conditions
• Sociology of health and illness:
• Health economics
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Module 13: Disorders of Childhood and Adolescence

Case studies: disorders of childhood and adolescence, learning objectives.

• Identify disorders of childhood and adolescence in case studies

Case Study: Jake

Jake was born at full term and was described as a quiet baby. In the first three months of his life, his mother became worried as he was unresponsive to cuddles and hugs. He also never cried. He has no friends and, on occasions, he has been victimized by bullying at school and in the community. His father is 44 years old and describes having had a difficult childhood; he is characterized by the family as indifferent to the children’s problems and verbally violent towards his wife and son, but less so to his daughters. The mother is 41 years old, and describes herself as having a close relationship with her children and mentioned that she usually covers up for Jake’s difficulties and makes excuses for his violent outbursts. [1]

During his stay (for two and a half months) in the inpatient unit, Jake underwent psychiatric and pediatric assessments plus occupational therapy. He took part in the unit’s psycho-educational activities and was started on risperidone, two mg daily. Risperidone was preferred over an anti-ADHD agent because his behavioral problems prevailed and thus were the main target of treatment. In addition, his behavioral problems had undoubtedly influenced his functionality and mainly his relations with parents, siblings, peers, teachers, and others. Risperidone was also preferred over other atypical antipsychotics for its safe profile and fewer side effects. Family meetings were held regularly, and parental and family support along with psycho-education were the main goals. Jake was aided in recognizing his own emotions and conveying them to others as well as in learning how to recognize the emotions of others and to become aware of the consequences of his actions. Improvement was made in rule setting and boundary adherence. Since his discharge, he received regular psychiatric follow-up and continues with the medication and the occupational therapy. Supportive and advisory work is done with the parents. Marked improvement has been noticed regarding his social behavior and behavior during activity as described by all concerned. Occasional anger outbursts of smaller intensity and frequency have been reported, but seem more manageable by the child with the support of his mother and teachers.

In the case presented here, the history of abuse by the parents, the disrupted family relations, the bullying by his peers, the educational difficulties, and the poor SES could be identified as additional risk factors relating to a bad prognosis. Good prognostic factors would include the ending of the abuse after intervention, the child’s encouragement and support from parents and teachers, and the improvement of parental relations as a result of parent training and family support by mental health professionals. Taken together, it appears that also in the case of psychiatric patients presenting with complex genetic aberrations and additional psychosocial problems, traditional psychiatric and psychological approaches can lead to a decrease of symptoms and improved functioning.

Case Study: Kelli

Kelli may benefit from a course of comprehensive behavioral intervention for her tics in addition to psychotherapy to treat any comorbid depression she experiences from isolation and bullying at school. Psychoeducation and approaches to reduce stigma will also likely be very helpful for both her and her family, as well as bringing awareness to her school and those involved in her education.

• Kolaitis, G., Bouwkamp, C.G., Papakonstantinou, A. et al. A boy with conduct disorder (CD), attention deficit hyperactivity disorder (ADHD), borderline intellectual disability, and 47,XXY syndrome in combination with a 7q11.23 duplication, 11p15.5 deletion, and 20q13.33 deletion. Child Adolesc Psychiatry Ment Health 10, 33 (2016). https://doi.org/10.1186/s13034-016-0121-8 ↵
• Case Study: Childhood and Adolescence. Authored by : Chrissy Hicks for Lumen Learning. Provided by : Lumen Learning. License : CC BY: Attribution
• A boy with conduct disorder (CD), attention deficit hyperactivity disorder (ADHD), borderline intellectual disability.... Authored by : Gerasimos Kolaitis, Christian G. Bouwkamp, Alexia Papakonstantinou, Ioanna Otheiti, Maria Belivanaki, Styliani Haritaki, Terpsihori Korpa, Zinovia Albani, Elena Terzioglou, Polyxeni Apostola, Aggeliki Skamnaki, Athena Xaidara, Konstantina Kosma, Sophia Kitsiou-Tzeli, Maria Tzetis . Provided by : Child and Adolescent Psychiatry and Mental Health. Located at : https://capmh.biomedcentral.com/articles/10.1186/s13034-016-0121-8 . License : CC BY: Attribution
• Angry boy. Located at : https://www.pxfuel.com/en/free-photo-jojfk . License : Public Domain: No Known Copyright
• Frustrated girl. Located at : https://www.pickpik.com/book-bored-college-education-female-girl-1717 . License : Public Domain: No Known Copyright

Psychology of Adolescence Development Case Study

Introduction, demographic data, developmental processes.

Adolescence is the transitional period of biological and mental development in the human lifecycle. It takes place between puberty and adulthood. The period is narrowly linked with teenage years. However, the physical, mental, and traditional elucidations may start earlier and terminate later than they should.

For instance, puberty is typically linked to adolescence progress. Adolescence starts before the teenage years. Practically, there are no universal standards that guide how adolescents behave. The communal setting where the adolescent is brought up is a major contributor to how they turn out as adults.

This case study originates from an interview conducted on 17-year-old Latino female. It is based on three development processes. These are biological, cognitive, and socio-emotional foundations of human development.

These foundations generate a vivid image of the adolescent’s experiences. Nicole Tomas’ experiences are paralleled to diverse prevailing age-related theories. The strategy allows the examination of the significance of adolescence as a standard stage of development. The approach helps in demystifying a bad perception of adolescents the community has.

Immigration from Latin America to the United States is typically an escape from challenging conditions. However, the advantage is accompanied by a loss of identity. The loss of identity is often distinctive baggage for adolescents. They are often placed into a new cultural setting and life situation during the process of forming an identity. US-born Latino adolescents also face the challenge of adapting to the majority culture. A major source of health issues for Latino adolescents is bicultural stress.

However, not all Latino adolescents experience health issues. Adolescence is associated with stress. It is also a stage when rebellion against norms occurs in the minds of the majority of adults.

However, this is not always the case because the majority of adolescents possess positive self-esteem and relate well with others. They eventually transit into adulthood effectively. The change in attitude and physical changes are triggered by hormones as they transit to adulthood. Amazingly, most adults tend to overlook their own experience as adolescents.

The objective of this case study is to examine the experiences of an adolescent Latino female. The approach will shed light on getting a better comprehension of what some adolescents have to cope within contemporary society. The use of the interview helps in demystifying misconceptions surrounding adolescence. Additionally, the interview helps in examining biological, cognitive, and socio-emotional aspects of Nicole Tomas. The interview will then be related to various theories of development.

Nicole is a Latino adolescent. She is 17 years old. She is a senior in a high school. Nicole is not an academically outstanding student. She enjoys singing and is in the school choir. She was raised by her father. Her mother died when Nicole and her elder sister were seven and ten years old, respectively. The bond between the sisters is strong.

This is possibly due to the absence of the mother with whom most girls have close relationships. Her father has always been there for them, but he is working most of the time. They only interact for two or three hours daily due to his tight schedule. When he is not working, he ensures he spends quality time with his daughters. This way, he creates a father-daughter bond with them. The relationship between the father and the daughters emerged out of necessity.

Biological Development

Nicole was born in a nearby hospital like a normal child. Her childhood was a happy one as her mother was not working; hence was always around her. She has tender memories about her mother who, she states, was very protective. Her father is not any different. Despite the protective nature of both parents, Nicole had to undergo the various developmental changes that normal childhood experiences.

Her father did not exhibit any difficulties in accepting the developmental changes that occurred in Nicole and her sister. He was supportive though he could not openly discuss with them the physical changes they experienced. Instead, he sought the assistance of their aunt, who would openly discuss various issues with them.

Nicole never experienced serious childhood diseases except for normal illnesses, such as chickenpox. However, she admits that she experienced a period of anxiety and distress upon the death of her mother when she was only seven years. The father and her aunt were there to support her psychologically.

Poor health, including obesity, is typically the result of lifestyles that begin in adolescence or when a child experiences poor upbringing (Santrock, 2000). Throughout their lives, the father has always made sure that their health is a precedence. When she caught chickenpox, her father took leave from work to be by her side. Although the aunt was there, he took it as his responsibility to personally take care of her.

Medical practitioners recommend that girls should have had a gynecological examination before they have reached 15 years. The father was aware of this. When Nicole was 14 years, the father arranged with the aunt for her to be taken to a gynecologist. The results were good. The physical development of girls occurred before and during the teenage years. Her puberty had set in when she got her first menstrual period.

The hips were developed, and breasts were formed. Girls are apprehensive about menstrual periods (Santrock, 2000). Nicole was not any different. She noticed that her breasts were developing rapidly. When her first menstrual period occurred, she was scared. She talked to her sister about it. Her sister, having experienced the same, told her that it was normal for a girl. Her aunt was also health-conscious. After Nicole’s 16 th birthday, she took her to a gynecologist for pelvic examination and Pap smear.

Nicole’s hobby is riding a bicycle. Riding helps her keep fit. However, when she was 14 years, she was used to overeating and did not want to do any exercises. Her weight increased rapidly. Her peers laughed at her. She cried for hours. Responding to this negative behavior, her father bought her a bike. Such a move enables girls to trust adults (Miller, 1993). Three months of physical exercise helped her regain her confidence as she had lost significant weight. Girls are sensitive about their physical appearance (Benokratis, 1999).

Adolescence is a period of sexual experimentation. Latino adolescents are said to be sexually less active as compared to their African American and White counterparts. Nicole admits that she had a boyfriend by the time she was 15 years. She has had a sexual experience. When her father noticed, he approached her aunt, who in turn talked to her. She says that although she still dates that boy, she stopped having sex with him. This may be denial on her part. Teenagers experience difficulty dealing with their sexuality (Fenwick 1994).

Cognitive Development

Piaget’s theory.

Nicole is capable of thinking abstractly, hence she is in Piaget’s formal operational stage. She can think about possibilities, such as how her father would react if he discovered that she might be having sex with her boyfriend. Having been exposed to books at an early age, she can create make-believe situations and possibilities. She is aware that she is not perceived as a typical teenager, which increases her self-esteem. However, she is cautious about what the others think about her and is determined to please those around her.

Adolescents typically show less concern for the others, especially, the underprivileged and the minority. Nicole hates this perception considering that she is Latino. However, her father can provide for her family. She despises the attitude of the society towards not caring for the disadvantaged. She feels that Whites use hate as a fabricated sense of supremacy. During her free time, she volunteers in the nearby children’s home as a way of contributing to society.

Socio-emotional Development

The 5 th stage in Erikson’s eight stages of the life cycle occurs in adolescence. This includes identity development. The adolescents are concerned with finding out who they are and where they are headed in life. Nicole appears to have significant knowledge of who she is. She can articulate her family lineage. By interacting with people from diverse races, she has developed a sense of self (Henslin, 1998). She has positive self-esteem. Proper upbringing has contributed to the development of her self-image and self-esteem.

Family Influence

Nicole says that her father involves her and her sister in making decisions. She states that since her 14 th birthday, the father demonstrated that he trusted her with decisions while he was away. When he returns, they sit and review the decision to gauge the rationality. The whole family is involved in financial decision-making. This is in concurrence with Fenwick (1994) who feels that this offers them an opportunity for self-expression and reasoning.

Environment

The environment is a determinant in the development of an individual (White, 2000). Nicole is aware of the dangers of drugs. She states that when her peers laughed at her weight when she was obsessed with food, she had contemplated using drugs. However, the positive relationship with her family helped her resist the temptation since they supported her.

Nicole also points out that she has a computer that she uses for learning using the Internet. However, she states that the Internet has influenced most of her friends as some watch pornography. She states that she uses her computer to interact with friends on social platforms.

The view of the society on adolescents emerges from personal experiences as it is shaped by the environment, including the media. The developmental changes during adolescence are often viewed negatively. The interview with Nicole reveals that adolescents probably become rebellious due to the treatment they receive from adults.

However, this is a development stage that shapes how the individual will turn out in adulthood. The negative perception of adults regarding adolescents has been prevalent for ages where adolescents are viewed as disorderly, stubborn, and disrespectful. The interview revealed that adolescents are not as bad as they are perceived to be. The knowledge gained is particularly useful for me as I now understand adolescents and the challenges they have to face and deal with.

Benokratis, V. (1999). Marriage and families: Changes, choices and constraints . Upper Saddle River, NJ: Prentice Hall.

Fenwick, E. (1994). Adolescence: The survival guide for parents and teenagers. New York, NY: Dorling Kindersley.

Henslin, J. (1998). Essentials of sociology: A down-to-earth approach. Needham Heights, MA: Allyn and Bacon.

Miller, H. (1993). Theories of development psychology. New York, NY: Freeman and Company.

Santrock, W. (2000). Children. New York, NY: McGraw-Hill.

White, F. (2000). Relationship of family socialization processes to adolescent moral thought. Journal of Social Psychology, 1(1) , 1-140.

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IvyPanda. (2020, April 3). Psychology of Adolescence Development. https://ivypanda.com/essays/psychology-of-adolescence-development/

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1. IvyPanda . "Psychology of Adolescence Development." April 3, 2020. https://ivypanda.com/essays/psychology-of-adolescence-development/.

Bibliography

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Cultural considerations in theories of adolescent development: a case study from Botswana

Affiliation.

• 1 University of Botswana, Gaborone, Botswana.
• PMID: 18293223
• DOI: 10.1080/01612840701792571

Western studies of adolescent development are beginning to corporate not only the traditional ideas of nature and nurture, but also contextual factors such as culture, ecology and historical time. This article explores how adolescent development is influenced by both a specific culture (Botswana) and a specific ecological situation (the rampant HIV pandemic in that country). A case study of late adolescents living in this pandemic in Botswana helps broaden our traditional views of adolescent development.

• Adolescent Behavior / ethnology*
• Adolescent Development*
• Attitude to Health / ethnology*
• Botswana / epidemiology
• Communication
• Endemic Diseases / prevention & control
• Endemic Diseases / statistics & numerical data
• Gender Identity
• HIV Infections / ethnology*
• HIV Infections / prevention & control
• Health Knowledge, Attitudes, Practice
• Intergenerational Relations
• Nursing Methodology Research
• Psychological Theory*
• Psychology, Adolescent
• Qualitative Research
• Risk-Taking
• Sexual Behavior / ethnology*
• Social Values

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Emily: A Case Study in Adolescent Development

Emily has developed before or along with her peers physically, cognitively, and psychosocially. Emily appears to be developing a healthy sense of Independence and self concept.

Finally, Emily Is healthy and appears to be progressing through puberty at a normal rate. Emily is a 12-year-old girl. Since birth she has lived with her mother Elizabeth in a small South Carolina town – population 60,000. She was an only child until three years ago when her brother Wade was born. Email’s mother Elizabeth is a single mother.

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Emily has never met her own father but had grown close to Wade’s father, ere step dad, when he died nine months ago from Hodgkin Lymphoma. Email’s mother According to Militias and Perkins (2010), a child’s family is central to their successful development. Their research suggests that children who are raised in non-traditional families are at a disadvantage Is all areas of development as well as socioeconomics. This case study will examine typical physical, cognitive, and psychosocial milestone of adolescent children and If 12-year-old Emily has been negatively affected In these areas as a result of her living In a single parent home.

LITERATURE REVIEW At 12 years old Emily is entering adolescence.

It is during adolescence that puberty begins. The time of adolescence is a time of rapid changes and physical growth in children. Rapid growth occurs in the bones and muscles, changes in body shape and size occur, and sexual maturation begins, essentially ending childhood. Beginning with hormonal changes, Including an increase in estrogen and progesterone, girls typically begin experiencing pubescent changes at the approximate age of eight.

Soon after, the uterus and vagina begin to grow larger and girls begin to develop erase buds.

Around the age of eleven, girls begin to develop pubic hair. Girls can expect their weight and height to increase during this time as well. As girls a girl’s Day Deigns to prepare Tort menarche, tenet nips will Decode wider. Nine menstrual period typically occurs around the age of twelve; however, this can happen earlier for some girls and much later for others. Puberty continues through the age of 18 as girls breasts fully develop and their first ovulation occurs (Berger, 2011).

In addition to sexual development during puberty, adolescents develop physically as well.

A growth spurt occurs during adolescence where nearly every body part grows, most notably at different and uneven rates. According to Berger (201 1), the fingers and toes of an adolescent grow longer before the hands and feet. The hands and feet grow longer before the arms and legs, and the arms and legs grow longer before the torso. It is not uncommon for an adolescent’s body to appear unsymmetrical. “One foot, one breast, or even one ear may grow later than the other,” (Berger, 2011 , p.

The hormones responsible for puberty and growth spurts in adolescent girls are also responsible for emotional changes. It is not uncommon for girls experiencing these hormone changes to have sudden outbursts of anger, sadness, or even lust. Neurological changes occur as the “limbic system, responsible for intense fear and excitement from the amazedly, matures before the frontal cortex, where planning ahead, emotional regulation, and impulse control occur,” (Berger, 2011, p 400). These neurological changes often lead adolescents to throw caution to the wind, especially in social situations.

Adolescents are more likely to act impulsively. Their impulsive behaviors coupled with their increase in hormones and interest in sexual activities outs adolescents at risk for sexual abuse and early pregnancy (Berger, 2011). During adolescence, physical and hormonal changes aren’t the only changes occurring. Brain maturation also occurs and cognitive growth increases. Adolescent children will experience increased independence, a heightened sense of self- consciousness, the ability to think more abstractly.

According to Swiss developmental psychologist and philosopher, Jean Pigged, adolescents develop the ability to use abstract logic, in contrast to children in early and middle childhood who primarily only have the ability to think in concrete terms (Congou, & Able, 2011).

In addition, during adolescence, identity struggles often begin. Developmental psychologist and psychoanalyst, Erik Erickson, described this stage of development as identity versus role confusion. According to Erickson, an adolescent’s mission during this state is to unearth who they are as individuals, apart from their families and as members of society at large.

Futile navigation of this stage, according to Erickson, results in role confusion and upheaval. Adolescents develop a sense of personal identity through many avenues including religion, politics, natural abilities, and gender. Merging holding events, social ideals, and their distinctive ambitions, identity is developed.

However, according to Erickson, adolescents seldom reach identity and role confusion is more probable (Badminton, 2009). Emily Is attending a Adulterant party Tort one AT near peers at cocoons. Nine party Is Delve held at a local church, in the church’s social hall.

According to Email’s mother this is not the first birthday party that Emily had attended where both boys and girls are present; however, it is the first co-De party that she has attended since she began showing an interest in boys. Most of the girls are wearing dresses and shoes with modest heels; their hair perfectly tended to with hints of gloss on their lips and blush on their cheeks. Emily wears blue Jeans, a blue and white stripped long sleeved shirt and boat shoes.

Her normal blond curls have been flattened with a straightening iron, according to her mother. Emily likes her hair better straight and she hates dresses.

Emily is tall, standing at 5 feet 6 inches tall. She weighs 150 pounds. Her body is well proportioned and she does not appear to be overweight. Emily has developed breasts and she has the appearance of some acne on her chin and forehead.

The overhead fluorescent lights are dimmed in the social hall but the area is lit well with blue, red, and green lights which flash in sync with the music playing over a pair of large speakers. A DC encourages the 28 eleven and twelve year olds to Join the only two boys on the dance floor. The room is divided. Girls stand near a row of metal folding chairs lining a wall.

The boys gather near a stage on the far end of the room. Email’s mother Elizabeth is also attending the party as a chaperone.

Elizabeth motions for Emily to come to her three times during a thirty minute period in an fort to encourage Emily to Join the others on the dance floor. Each time Emily ignores her mother’s encouragements. The third time Email’s eyes grow wide and from across the room she mouths the word “stop” to Elizabeth. Nearly an hour into the party, the girls scream with delight when a popular song begins to play and several rush to the dance floor.

Emily rushes to the dance floor with a number of other girls and they begin to dance to the music. Song after song, Emily and her group of friends stay on the dance floor.

They stop occasionally to chat with one another but never leave the dance floor. Emily dances and laughs with her female friends for nearly an hour before the group is called to have birthday cake and watch as the birthday girl opens presents. While the children are eating Emily socializes with both her female and male friends. She is particularly friendly with a male named Dawson.

The two stand beside one another and talk while their friend opens her birthday presents. She playfully hits him on the arm six times during their exchange.

She blushes as he playfully hit her back. Soon the group of adolescents is back on the dance floor for another half hour of dancing before the party is over. This time both the boys and girls are on the dance floor together. Emily dances alongside both her female and male friends for the remainder of the party. As the party comes to close, Emily hugs each one of her female friends’ goodbye as they leave.

When Elizabeth summons Emily to leave the party, Emily shouts out to Dawson, telling him goodbye. On Sunday rotenone, Elation welcomes me to spend time Witt Emily In ten Tamale’s home. Email’s family lives in a modest three bedroom, two bath house in a popular neighborhood on the North side of town. Their large fenced in back yard is filled with right colored, plastic play-things belonging to Email’s younger brother Wade. Email’s purple Next bicycle leans against a wall in the home’s garage.

The bicycle is much too small for her growing stature and Emily readily admits that she hasn’t ridden the bike in at least a year.

Nothing else in the yard or garage suggests that a young girl live there but inside the home tells a different story. On the kitchen counter lays a knotted green ribbon with long blonde hairs tangled within the knot. Emily explains that she wore the ribbon on SST. Patriot’s Day this year because she had no other green in her wardrobe. Lying on the family couch is a blue and purple fleece blanket and a fuzzy heart-shaped fuchsia pillow donning the words “Drama Queen.

” It’s Email’s favorite pillow. The floor in the living area is scattered with green toy tractors and an incomplete train set.

Leaving the living area and entering the long narrow hallway, Email’s bedroom is the first room on the left. Her doorway stands open but a handmade foam door hanger hangs from the door knob reading “Do Not Enter. ” Email’s room is pink and while with accents of black and grey.

Her hot pink sheets peek out from under the wrinkled black and white polka dot comforter on her bed. Her bedroom walls are adorned with pictures of her favorite singers, Cody Simpson and Selene Gomez. A large bean bag chair takes up much of the floor space in her bedroom.

A large bookcase runs nearly the length of one wall while a keyboard and microphone stand sit against the opposite wall. Emily loves to sing and often spends a great deal of her time singing along with her favorite musicians on her karaoke machine.

A framed piece of child-drawn art hangs to the right of her bed. Emily says she completed the work in third grade. It depicts a boy who is seemingly stuck inside of a glass bottom room. Emily explains the technique she used is called foreshadowing. When asked if it has an underlying leans, Emily whips her hair and nonchalantly replies that it does not.

Emily is welcoming and excited to show off her space and her things, including her three dance trophies and her second place youth photography ribbon she won at last year’s South Carolina Festival of Flowers.

Emily is creative and has an artistic side through her love of music, photography, drawing and painting, and dance. I inquire more about Email’s art work and she pulls from her closet several pieces of art work sandwiched between two pieces of cardboard. She ruefully pulls out several pieces of art and tells me how old she was when she completed it.

Before we can finish, Email’s phone alerts her that she has a text message. For the next 15 minutes Emily sends and receives text messages from her cell phone.

She tells me that she is discussing an upcoming school trip to Philadelphia with her friend Jenny. They are discussing room arrangements. After testing with Jenny, Emily shows me information she has printed from the internet pertaining to her trip to Philadelphia. Emily says she is excited about the trip as she has never been away from home for more than two or three days at a time. She will be in Philadelphia for six days.

Emily says she cannot wait to go and excitedly explains how she will be staying in a hotel room with three of her female friends, without an adult. Emily explains that the girls will stay on the third floor of the hotel while the boys will stay on the second floor. Emily receives another text message Just as I am leaving. Seen says gooey walkout looking up Trot near cell phone. INTERVIEW Elizabeth is a thirty-two year old mother of two.

She gave birth to Emily at the age of nineteen. Emily was born December 10, 1999 by cesarean section after a full term pregnancy.

Email’s mother Elizabeth reports no prenatal problems and no complications during labor. At birth Emily weighed seven pounds and eleven ounces. She was twenty one inches long. According to the Centers for Disease Control (2000) Email’s weight put her in the thirty sixth percentile for newborns and her height put her in the ninety third percentile for newborns.

As an infant, Emily was breast fed for seven months, according to Elizabeth. Elizabeth explains that as an infant, a toddler, and a young child, Emily hit all of her developmental milestones early, including puberty which began for Emily around age nine.

Email’s father is not active in Elizabeth and Email’s lives. Emily has never met her father. Elizabeth explains that Email’s father attended college with her. They were casually dating when Elizabeth became pregnant.

Email’s father did not want anything to do with Elizabeth after she told him she was pregnant. After finding out that she was pregnant, Elizabeth quit school until she gave birth to Emily then quickly returned to finish her degree. Elizabeth obtained a four year degree in marketing from a local college when Emily was three.

She now works for a major hotel chain as their director of communications. Elizabeth earns $43,000 annually.

She has no other income. Elizabeth grew up in the Catholic Church but left the church as a teen. Today she is a member off local Presbyterian church. Elizabeth considers herself an authoritative parent. She says that while she has great deal of expectations for her children, she also has a close and warm relationship with each of them.

She says her relationship with Emily has become closer since Emily has begun middle school.

Elizabeth believes that it is most important that her children trust her. She explains that she wants her children to feel as if they can talk to her about anything. Elizabeth expects Emily to perform well in school and says Emily has not ever been in trouble at school because Elizabeth does not tolerate disobedience, especially in school. Elizabeth believes she holds the three traits that she says make a great parent: she commands respect; she works constantly to ensure good communication with her children so that they trust her, and she has clear expectations of her children.

Elizabeth says that if she were to give new parents three pieces of advice she would impress upon them how quickly time passes. “Enjoy every minute, and don’t take one second for granted,” she says. Elizabeth says she loud also tell new parents to make sure they make time for themselves. Finally, Elizabeth says she would tell them to be honest with their children. “Share your life experiences with them. Tell them the things you did right and the things you did wrong.

Tell them about the lessons you’ve learned. Children learn to respect you and trust you in that sense. Emily is nine months shy of her thirteenth birthday. Emily is five feet, six inches tall. She weighs one hundred and fifty pounds. According to the Centers for Disease Control (2000), Email’s height is greater than the ninety seventh percentile for height.

Emily is at the ninety seventh percentile for weight. Although Emily is taller and heavier than more than ninety five percent of her peers, according to her mother, Emily has hit developmental milestones earlier than her peers since she was an infant. Furthermore, Emily is currently experiencing puberty, an expected occurrence at her age.

She has developed breasts and she has had her first menstrual period. Emily is not sexually active, according to her mother and therefore she is currently not at risk for early pregnancy. Cognitively, Emily is progressing as a typical 12 year old girl.

She displays eagerness o establish a sense of independence from her mother with her upcoming school trip to Philadelphia. She looks forward to being away from her mother, and proving to both her mother and herself that she is maturing in the ability to make her own choices.

Email’s cognitive development is also apparent in the choices she made when dressing and styling her hair for the birthday party she attended. Email’s mother explained that Emily used a straightening iron on her hair because she was not fond of her naturally curly hair. This demonstrates that Emily has developed a sense of self-consciousness.

Lastly, Email’s psychosocial development is apparent in that Emily is working to develop her own identity. Although Email’s friends wore dresses to the birthday party, Emily opted for blue Jeans and boat shoes.

Emily chose to wear what she was comfortable wearing instead of what social norms would have her wear. In addition, Emily knows what she loves. She immerses herself in her art, her music, and her photography.

While her friends are participating in sports and trying out for cheerleaders, Emily is comfortable in her own vocation and does not seem eager to change. SUMMARY Emily is a typically developing 12 year old girl. It does not appear that her physical, cognitive, and psychosocial development has been negatively affected by her growing up in a single parent home.

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A closer look into the affect dynamics of adolescents with depression and the interactions with their parents: An ecological momentary assessment study

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• Open access
• Published: 18 May 2024

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• Loes H.C. Janssen   ORCID: orcid.org/0000-0003-3543-6026 1 , 2 ,
• Bart Verkuil 1 , 2 ,
• Lisanne A.E.M. van Houtum 1 , 2 ,
• Mirjam C.M. Wever 1 , 2 ,
• Wilma G.M. Wentholt 1 , 2 &
• Bernet M. Elzinga 1 , 2  

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Adolescents with depression tend to perceive behavior of parents as less positive than adolescents without depression, but conclusions are based on retrospective reports assessed once or over long time intervals, with the risk of memory biases affecting the recall. The current study used ecological momentary assessments to examine the link between adolescent affect and the amount of warmth and criticism expressed by both mothers and fathers in families with adolescents with depression versus adolescents without psychopathology in daily life. It also explored the possible bias by assessing parenting on the momentary, daily (EMA), and retrospective level. The sample consisted of 34 adolescents with depression and 58 parents and 80 healthy controls and 151 parents (adolescents: M age = 15.8, SD  = 1.41; 67.5% girls, parents: M age = 49.3, SD  = 5.73; 54.1% mothers). Participants completed retrospective questionnaires and four surveys a day for 14 consecutive days. Preregistered multilevel models showed that momentary parenting reports of adolescents with depression and healthy controls did not differ. The associations between perceived parenting of both mothers and fathers and adolescent affect did also not differ between the two groups. These results illustrate that adolescents generally benefit from supportive parenting, but substantial differences between individuals were found. In contrast to the momentary data, both adolescents with depression and their parents did report more negative parenting on retrospective questionnaires than healthy controls and their parents indicating that adolescents with depression may have a negativity bias in their retrospective recall. These findings are highly relevant for clinical practice and underscore the need for careful assessments on different time scales and including all family members.

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The prevalence of mood disorders increases substantially during adolescence [ 1 ] and an early onset has been associated with higher recurrence rates [e.g., 2 ] and adverse psychosocial outcomes in adulthood [e.g., 3 ]. One of the key interpersonal factors that affects adolescent well-being is the relationship with parents [ 4 ]. Findings based on observational and retrospective self-report studies showed that a lack of warmth and critical parenting are related to depression in adolescents, but also that adolescent depression can impact parenting [ 5 , 6 , 7 ]. These studies, however, mainly focused on retrospective reports on parenting and may involve recall bias [ 8 ] which may be amplified for adolescents with depression [ 9 ]. Moreover, these studies focused on how families differed in their levels of parenting (between-family level), while parenting can change from day to day, and each family is unique with distinct parent-adolescent dynamics [ 10 , 11 ]. Zooming in to the daily and moment-to-moment experiences of parent-adolescent interactions and the associations with the adolescent affect can provide valuable insights for clinical interventions. By using ecological momentary assessment [EMA; 12 ] we aimed to examine the link between parental warmth and criticism of mothers and fathers and adolescent affect in families with adolescents with depression (i.e., a current major depressive disorder (MDD) or dysthymia; DEP) and families with adolescents without psychopathology (i.e., healthy controls; HC). Additionally, we explored the possible impact of recall bias on parenting reports by assessing parenting on the momentary, daily level (both based on EMA), and a more global, retrospective level (using questionnaires).

Parent-adolescent interactions characterized by lack of warmth and support and elevated levels of conflict and criticism have been consistently linked to depression in adolescents [e.g., 5 , 6 , 7 , 13 ] and depression later in life [ 14 , 15 , 16 ]. Most of this evidence, however, is based on retrospective self-report questionnaires assessed once or spanning large time intervals (e.g., last year). To overcome potential reporter bias, observational studies have been used to gain insights into the more fine-grained dynamics between parents and adolescents. These studies show that low levels of parental positivity relate to depression in children and adolescents, but findings are more mixed, probably also due to the variety of tasks and coding systems [see for review 17 ]. Still, an important limitation here is that it does not capture the daily life dynamics in a natural context in which parent-adolescent interactions occur [ 8 ]. Recent studies have shown that parenting is highly dependent on the context and can fluctuate over time (i.e., hours or days) within a family or person [ 18 , 19 , 20 ], but research addressing these everyday family dynamics in clinical samples of adolescents is limited.

To date, 12 EMA studies investigated affect in adolescents with a clinical depression [see review 21 ]. Some studies found that adolescents with mood disorders report lower levels of positive affect and higher levels of negative affect than healthy controls [ 22 , 23 ], but others did not find differences in affect between depressed and non-depressed adolescents [ 24 , 25 , 26 ]. While EMA enables assessing the naturalistic dynamic setting of adolescents’ daily life, only three studies examined the social context (i.e., amount of time spent together or co-rumination with peers or family) of adolescents with depression [ 23 , 27 , 28 ]. Quality of time spent together with parents was, however, not assessed. This is an important omission, given the importance of parenting for adolescent well-being [e.g., 5 , 6 ]. As a next step, we therefore examined whether momentary positive and negative affect as well as momentary parental warmth and criticism (from both adolescents’ and parents’ perspective) during parent-adolescent interactions differed between families with a DEP adolescent and families with a HC adolescent. Moreover, we compared parenting reports between families with DEP adolescents and HCs on different time scales: momentary, daily, and retrospective, to explore whether a recall bias [ 8 ] may influence parenting reports.

Previous studies in community samples have shown that on moments or days when adolescents perceive more parental warmth and less parental conflict, they report less negative affect and more positive affect [ 29 , 30 , 31 ]. Moreover, the strength of this association may differ between adolescents explained by depressive symptoms. For adolescents who reported more depressive symptoms, stronger associations were found between (a lack of) daily parental support and conflict and adolescent negative affect compared to adolescents who reported less depressive symptoms [ 29 , 30 ]. On the momentary level, depressive symptoms only explained differences in associations over time [ 31 ]. For instance, adolescents with more depressive symptoms experienced a stronger increase in positive affect after a warm interaction with their parent. Although these studies provided some first insights, it is essential to include a clinical sample to investigate whether this also holds in adolescents with clinical depression, which is important for the ultimate goal of guiding clinical practice.

This preregistered study ( https://osf.io/qjyp5 ) aimed to (1) examine whether adolescent momentary positive and negative affect and momentary parental warmth and criticism during parent-adolescent interactions differed between families with a DEP adolescent and HCs, (2) assess the within-person momentary association between perceived parenting behavior and affect during parent-child interactions, and (3) examine whether this association is stronger for DEP adolescents. We hypothesized that: 1a) DEP adolescents report less momentary positive and negative affect than HCs; 1b) DEP adolescents and (1c) their mothers and fathers report less parental warmth and more parental criticism during momentary parent-child interactions than HCs; 2) more perceived parental warmth and less perceived parental criticism of mothers and fathers at a given moment is associated with more positive and less negative affect at the same moment; 3) the associations between perceived parenting of mothers and fathers and adolescent affect during momentary parent-adolescent interactions are stronger for DEP adolescents compared to HCs. After preregistration, we added an exploratory aim: comparing parenting reports on the momentary, daily level (both based on EMA), and retrospective level (questionnaires) of families with DEP adolescents and HCs.

Data were used from RE-PAIR (Relations and Emotions in Parent Adolescent Interaction Research), which examines parent-adolescent interactions and adolescent mental well-being by comparing DEP adolescents and their parents to HC adolescents and their parents. The RE-PAIR study consisted of four parts: online questionnaires, a research day at the lab, two weeks of EMA, and an Magnetic Resonance Imaging (MRI)-scan session with the adolescent and one parent. The current study focused on the EMA part of RE-PAIR and also included several online questionnaires. The RE-PAIR study was approved by the Medical Ethics Review Committee (METC) of Leiden University Medical Centre (LUMC; research protocol: P17.241).

Families were included in the study if adolescents: were aged between 11 and 17 years when screened for psychopathology, started secondary school, lived with at least one primary caregiver who wanted to participate, and had a good command of the Dutch language. Participation with two parents – if possible – was preferred but this was no requirement. DEP adolescents had to meet criteria for a current MDD or dysthymia as primary diagnosis, and no other primary (neuro)psychiatric disorder or comorbid psychosis, substance use disorder or mental retardation. For HC adolescents, a lifetime MDD/dysthymia diagnosis, a current mental disorder, or a history of psychopathology in the last two years were exclusion criteria. Adolescent psychopathology was assessed with the Kiddie-Schedule for Affective Disorders and Schizophrenia – Present and Lifetime Version [K-SADS-PL; 32 ]. All participants signed informed consent. If adolescents were younger than 16 years of age, parents with legal custody also signed informed consent for the adolescent. For detailed information on sample recruitment and study procedure see Appendix 1 .

In total, 114 families participated in the EMA of RE-PAIR: 80 HCs and their 151 parents, and 34 DEP adolescents and their 58 parents. Current primary diagnosis was MDD for 28 adolescents (82.4%) and dysthymia for 6 adolescents (17.6%). See Appendix 2 for comorbidity of adolescents and psychopathology of parents. Due to a branching error in questionnaires of one HC adolescent, we excluded that family resulting in a final sample of 79 HCs and 149 parents. Table  1 provides sample demographics. The majority of adolescents (96.3% HCs; 91.2% DEP adolescents) and parents (94.6% parents of HCs; 82.8% parents of DEP adolescents) were born in the Netherlands.

All participants received four questionnaires a day for 14 consecutive days (56 in total) on the Ethica app on their own smartphone. Questionnaires were triggered between 7AM and 9.30PM on weekdays and 9AM and 9.30PM on weekend days according to a standardized trigger schedule (detailed information in Appendix 3 and full codebook of EMA: https://osf.io/dcemq/ ). The EMA of RE-PAIR was conducted between September 2018 and March 2022. As compensation for EMA, parents received €20,- and HCs received €10,-. DEP adolescents did not receive compensation for the EMA since the assessments were considered as valuable information that could generate new insights and potentially facilitate the treatment due to possible self-insight. Treatment was not part of RE-PAIR and took place in regular clinical outpatient settings. To limit potential confounding influence of treatment, families who received parenting interventions or family-based treatment were not able to participate in RE-PAIR. Additionally, six gift vouchers of €75,- were raffled among all participating families based on compliance of EMA questionnaires completed by the family.

DEP adolescents fully completed 1193 (63.8%) of the delivered questionnaires and answered on average 35.1 questionnaires ( SD  = 13.9, range 11–55). In 554 cases (46.4% of answered questionnaires), adolescents indicated that they had interacted with one or both parents who participated in the EMA of RE-PAIR ( M  = 16.3 parent-adolescent interactions per participant, Range = 2–33). Parents fully completed 2329 (72.8%) of the delivered questionnaires and answered on average 40.2 questionnaires ( SD  = 9.7, range 11–53).

HCs fully completed 2930 (68.3%) of the delivered questionnaires and answered on average 37.1 questionnaires ( SD  = 11.2, range 3–55). In 1426 cases (48.7% of answered questionnaires), adolescents indicated that they had interacted with one or both parents who participated in the EMA of RE-PAIR ( M  = 18.1 parent-adolescent interactions per participant, Range = 3–42). This did not differ significantly from DEP adolescents ( p  = .334). Parents fully completed 6582 (80.5%) of the delivered questionnaires and answered on average 44.2 questionnaires ( SD  = 8.2, range 16–56). No participants were excluded based on missing data and all completed EMA data was retained for analyses.

Momentary positive and negative affect . Adolescents rated their momentary affect using an adapted and shortened four-item version of the Positive and Negative Affect Schedule for Children [PANAS-C; 33 , 34 ]. Two positive affect states (happy and relaxed) and two negative affect states (sad and irritated) were assessed by asking “How do you feel at this moment?” followed by: “Happy”, “Relaxed”, “Sad”, and “Irritated”. Answers were given on a 7-point Likert type scale ranging from 1 ( not at all ) to 7 ( very ). An average score of the two positive affect states was calculated, with the two items being strongly correlated at the between person-level, r  = .830, p  < .001, and moderately at the within-person level, r  = .463, p  < .001. An average score of the two negative affect states was calculated, with the two items being strongly correlated at the between person-level, r  = .765, p  < .001, and moderately at the within-person level, r  = .335, p  < .001. See Appendix 4 for correlations.

Momentary positive and negative affect during parent-adolescent interaction . Adolescents were asked with whom they spoke last to or with since the last beep and could select parents, friends, others, or no one. If they indicated they spoke last to or with mother, father or both follow-up questions were asked about this interaction. Adolescents rated their momentary affect during the interaction with an adapted and shortened five-item version of the Positive and Negative Affect Schedule for Children [PANAS-C; 33 , 34 ]. Two positive affect states (happy and relaxed) and three negative affect states (sad, irritated, and guilty) were assessed by asking “How did you feel during this contact?” followed by: “Happy”, “Relaxed”, “Sad”, “Irritated”, and “Guilty”. Guilt, often part of or accompanying adolescent depression [ 35 ], was only assessed after interactions since parents and parenting can induce guilt during interactions [ 5 ]. Answers were given on a 7-point Likert type scale ranging from 1 ( not at all ) to 7 ( very ). For the current study, only answers about interactions with parents who participated in the EMA were included. An average score of the two positive affect states was calculated, with the two items being strongly correlated at the between person-level, r  = .838, p  < .001, and moderately at the within-person level, r  = .428, p  < .001. An average score of the three negative affect states was calculated, with the three items being strongly correlated at the between person-level, range r  = .543–0.670, p  < .001, and moderately to low at the within-person level, range r  = .161–0.335, p  < .001. See Appendix 4 for correlations.

Parenting during parent-adolescent interaction. Adolescents rated parenting behavior during the interaction, if they indicated that they spoke last to or with their parent(s), by answering the questions “How well did your mother/father listen to you?”, “How well did your mother/father understand you?”, “How critical was your mother/father towards you?”, and “How dominant was your mother/father?”. Answers were given on a 7-point Likert type scale with answer categories ranging from 1 ( not at all ) to 7 ( very ).

Similarly, if parents indicated that they spoke last to or with their adolescent since the last beep, they rated their own parenting behavior during the interaction. They answered the questions “How well did you listen to your child”, “How well did you understand your child?”, “How critical were you towards your child?”, and “How dominant were you towards your child?”. Answers were given on a 7-point Likert type scale with answer categories ranging from 1 ( not at all ) to 7 ( very ). Two subscales were created for parents and adolescents separately, parental warmth and parental criticism. An average score of listening and understanding behavior during the interaction was calculated to assess parental warmth, with the two items being strongly correlated at the between person level, range r  = .763–0.949, p  < .001 and moderately to strongly at the within-person level, range r  = .415–0.697, p  < .001. An average score of critical and dominant behavior during the interaction was calculated to assess parental criticism, with the two items being strongly correlated at the between person level, range r  = .520–0.724, p  < .001 and strongly at the within-person level, range r  = .562–0.657, p  < .001. See Appendix 4 for correlations.

Daily parenting . In the last questionnaire of each day, adolescents indicated whether they spoke to a parent during that day and with whom (i.e., mother, father, stepmother, stepfather). Adolescents rated daily parenting for each parent they spoke to by answering the questions: “Throughout the day, how critical was your mother/father towards you?” and “Throughout the day, how warm/loving was your mother/father towards you?” Answers were given on a seven-point Likert type scale ranging from 1 ( not at all ) to 7 ( very ). Similarly, parents indicated whether they spoke to the participating adolescent in the last questionnaire of each day. Parents rated their own behavior by answering the questions “Throughout the day, how critical were you towards your child?” and “Throughout the day, how warm/loving were you towards your child?” Answers were given on a seven-point Likert type scale with answer categories ranging from 1 ( not at all ) to 7 ( very ).

Depressive symptoms . The Patient Health Questionnaire [PHQ-9; 36 ] was used to assess adolescent depressive symptoms the past two weeks as part of the online questionnaires adolescents had to complete before the research day in the lab. The items are based on nine DSM-IV criteria for depression and are rated as 0 ( not at all) to 3 ( nearly every day ). One item (item 8; moving or speaking slowly or being so fidgety or restless) was split in two items and the maximum score of these two items was included. Sum scores range from 0 to 27 and a score above 10 is suggestive of the presence of depression [ 37 ]. Cronbach alpha was 0.94.

Parental bonding. To assess the parent-adolescent bond, adolescents completed the Dutch version of the Parental Bonding Inventory [PBI; 38 ] as part of the online questionnaires. Adolescents reported on the bond with mothers and fathers separately and only reports about parents who participated in the EMA were included. The instrument consisted of 25 items and included three subscales: care (12 items), overprotection (6 items), and lack of autonomy (7 items) [ 39 ]. Answers were given on a 4-point Likert scale ranging from 0 ( very like ) to 3 ( very unlike ). Since wording of one item of lack of autonomy subscale deviated from the original PBI and showed inconsistent loading [ 39 ], we excluded the item from the subscale in the current study. After reverse coding 13 items, a sum score per subscale was calculated and higher scores indicated more care, overprotection, and lack of autonomy. Cronbach’s alphas in the current sample regarding care, overprotection, and lack of autonomy with mothers were α = 0.88, α = 0.62, and α = 0.82 respectively. Regarding care, overprotection, and lack of autonomy with fathers Cronbach’s alphas were α = 0.87, α = 0.59, and α = 0.71 respectively.

In order to also assess the parent-adolescent bond from the perspective of parents we rephrased the items of the PBI. Cronbach’s alphas for PBI of parents were α = 0.77 for care, α = 0.58 for overprotection, and α = 0.64 for lack of autonomy.

Childhood emotional maltreatment. To assess experienced childhood emotional maltreatment, adolescents filled out the Dutch version of the Childhood Trauma Questionnaire short form as part of the online questionnaires [CTQ-SF; 40 , 41 ]. The full CTQ-SF consists of 25 items including five subscales. The current study uses two subscales: emotional abuse and emotional neglect. Both subscales consist of five items and were answered on a Likert scale, ranging from 1 ( never true ) to 5 ( very often true ). Five items were reverse coded before calculating a sum score per subscale. Higher scores indicating more experienced childhood emotional maltreatment. Overall, the CTQ-SF has been shown to have high reliability and validity [ 41 , 42 ]. Validity in an adolescent sample has also been shown [ 43 ]. In the current sample Cronbach’s alphas were α = 0.82 for emotional abuse and α = 0.84 for emotional neglect.

Preregistered analyses

Our analysis plan, including power analyses, was preregistered online ( https://osf.io/qjyp5 ). As the amount of observations of interactions of adolescents with fathers was less than expected, we performed some sensitivity checks (see Appendix 5 ). For the analyses we used R version 4.0.1 [ 44 ] and for the multilevel package version 2.6 with ML estimation. Level 1 predictors were person-mean centered, following guidelines proposed by [ 45 ] and [ 46 ].

To account for the nestedness of the data (i.e., measurements nested in individuals) we used multiple multilevel models. We ran two-level models instead of three-level models (moments nested in days nested in individuals) as some adolescents on some days did not or once indicated an interaction with their parent(s). To examine whether adolescent momentary positive and negative affect (in general and during parent-adolescent interactions) and momentary parental warmth and criticism during parent-adolescent interactions differed between families with a DEP adolescent and HCs (aim 1) we tested eight models including adolescents’ reports and four including parents’ reports. Although not preregistered, we also compared momentary, daily, and retrospective reports of parenting between the two groups to explore recall bias using multilevel models (momentary and daily level) and appropriate non-parametric tests (retrospective reports). To investigate the within-person association between perceived parenting behavior and adolescent affect during parent-adolescent interactions (aim 2), we added the person-mean centered scores of perceived maternal warmth, perceived maternal criticism, perceived paternal warmth, and perceived paternal criticism to the unconditional random intercept models of positive and negative affect separate (eight models). Next, in each model, variation was allowed around the slope to examine heterogeneity. Likelihood ratio tests were used to assess differences in fit of the models [following guidelines of 47 ]. To assess whether the association between parenting and adolescent affect during parent-adolescent interactions was stronger for DEP adolescents (aim 3), we added the binary variable clinical status (0 = HCs, 1 = DEP adolescents) to the model as main effect and in interaction with perceived parenting. Lastly, we explored whether the association between parenting and adolescent affect during parent-adolescent interactions was stronger for adolescents with more depressive symptoms. This level 2 predictor was grand-mean centered.

Correlation structure corCAR1 was added in all models to take into account unequally spaced time intervals [ 48 ].

Differences between DEPs and HCs

Descriptive statistics of the study variables and results of multilevel models are presented in Table  2 (see Appendix 6 for correlations). DEP adolescents reported significantly less momentary positive and more negative affect than HCs ( p’ s < 0.001, see Fig.  1 ). During parent-adolescent interactions, DEP adolescents reported significantly less positive and more negative affect than HCs ( p ’s < 0.001, see Fig.  2 ). DEP adolescents did not differ from HCs in their perceptions of perceived parental warmth and parental criticism of mothers and fathers during parent-adolescent interactions (all p ’s > 0.050, see Fig.  2 ). Similarly, mothers’ and fathers’ own perception of parental warmth and criticism did not differ between parents of DEP adolescents and HCs (all p ’s > 0.050).

Average fluctuations of momentary positive and negative affect of adolescents over time per group, HC adolescents and DEP adolescents

Average fluctuations of momentary adolescent affect and perceived parenting during parent-adolescent interactions per group over time (observations). Panel A and B represent interactions with mothers reported by HC adolescents and DEP adolescents respectively. Panel C and D represent interactions with fathers reported by HC adolescents and DEP adolescents respectively

On the daily level, DEP adolescents reported lower levels of perceived parental warmth of mothers and fathers than HCs ( p ’s < 0.05, see Table  1 ), whereas levels of perceived criticism did not significantly differ. Parents’ self-reported daily parental warmth and criticism (assessed at the end of the day) did not significantly differ between the two groups. Retrospectively, using appropriate non-parametric tests, DEP adolescents reported higher levels of parental emotional abuse and neglect during their childhood compared to HCs ( p ’s < 0.001) and less care and more overprotection from mothers and fathers than HCs ( p’ s < 0.01). Parents of DEP adolescents also reported less care, more overprotection, and more lack of autonomy compared to parents of HCs ( p ’s < 0.05).

Within-person associations

As indicated by the intraclass correlations (ICC) 57.4% of the variance in adolescent negative affect and 60.8% of the variance in adolescent positive affect was due to differences between adolescents, and 42.6% and 39.2% due to within-person fluctuations over time. Examination of the within-person association between perceived parenting behavior and affect during momentary parent-adolescent interactions (aim 2) showed that when adolescents perceived their mothers and fathers to show more warmth or less criticism during interactions, they also reported more positive and less negative affect (all p ’s < 0.001, see Appendix 7 ). Next, we allowed variation around the slope of perceived parenting in each model and likelihood ratio tests indicated that this improved the model fits significantly (all p ’s < 0.001), This indicates that adolescents differed substantially in the extent to which perceived parental warmth and criticism of mothers and fathers were associated with positive and negative affect.

To examine whether the association between perceived parenting and adolescent affect during momentary parent-adolescent interactions differed between DEP adolescents and HCs (aim 3), we added clinical status (being diagnosed with depression or not) to the models as well as an interaction of clinical status with perceived parenting. Results are displayed in Table  3 . In all models, there was no significant interaction between perceived parenting and clinical status, indicating that the link between perceived parenting and adolescent affect did not differ between DEP adolescents and HCs (see Appendix 8 for figures). Further inspection of these associations in DEP adolescents indicated that even within this group, there are individual differences in how parenting and adolescent affect are related. This is illustrated in Fig.  3 in which individual associations between parental warmth of mothers and negative affect during momentary parent-adolescent interactions were plotted for DEP adolescents.

Individual-level associations between parental warmth of mothers and negative affect during momentary parent-adolescent interactions for DEP adolescents. Each line represents one person

We furthermore explored whether the association between parenting and adolescent affect during parent-adolescent interactions differed based on severity of depressive symptoms instead of clinical status. Findings were similar compared to clinical status and indicated that the link between perceived parenting and adolescent affect during parent-adolescent interactions did not differ between adolescents based on the severity of depressive symptoms. Full model results are presented in Appendix 9 .

Sensitivity analyses

In addition to our preregistered analyses, we conducted three post hoc sensitivity analyses. First, to tease apart within- from between-person associations, we calculated the person-mean of perceived parenting and added the grand-mean centered score to the model including perceived parenting and clinical status. Average perceived parenting was significantly associated with adolescent affect (all p ’s < 0.01) in all models. Results on daily perceived parenting and clinical status did not change from previous models (see Appendix 10 ). Second, to control for the possible influence of time, we added the observation variable (a count variable ranging from 1 to 56) to the models including perceived parenting and clinical status (see Appendix 11 ). Results on daily perceived parenting and clinical status remained the same, but time was a significantly related with adolescent positive affect ( p ‘s < 0.01) except in the model with parental criticism of fathers. Third, to elucidate whether the association between perceived parenting and adolescent affect during parent-adolescent interactions differed between boys and girls, we included perceived parenting, clinical status (as main effect), sex, and an interaction between sex and perceived parenting in the models. The interaction between sex and perceived parenting was not significant, indicating that the link between perceived parenting and adolescent affect did not differ between boys and girls (see Appendix 12 for full model results). Sex itself was also not significantly related to adolescent positive and negative affect in the models including maternal warmth and criticism. However, when inspecting the models focusing on the interactions between adolescents and fathers, adolescent girls reported less positive and more negative affect than boys during interactions with their fathers (all p ’s < 0.050).

We examined the moment-to-moment experiences of adolescent affect and parenting during parent-adolescent interactions in a clinical sample of families with DEP adolescents in comparison to families with HCs. In line with our preregistered hypotheses and some previous research [ 22 , 23 ], we found that DEP adolescents experienced lower levels of positive affect and higher levels of negative affect than HCs throughout the days as well as during parent-adolescent interactions. As illustrated in Fig.  1 , on average DEP adolescents reported little below the middle of the scale (ranging from not at all to very) which may indicate a more flat or blunted affect. This seems to be partly in line with the Emotion Context Sensitivity theory that proposes that depression flattens emotions in general [ 49 ].

In contrast to our hypotheses, momentary levels of reported parental warmth and criticism during parent-adolescent interactions did not differ between the two groups, not from the perspective of the adolescent nor from the parent (i.e., mother and father). On a daily level, parental criticism did not differ between the two groups, but DEP adolescents did perceive their parents to be less warm. Moreover, adolescents with DEP also perceived their relationship with mothers and fathers as more negative (e.g., less care, more overprotection, more emotional abuse and neglect) as indicated on the retrospective questionnaires compared to HCs. Parents of DEP adolescents themselves also reported less parental care and more overprotection on the retrospective questionnaires than parents of HCs. These discrepancies are intriguing, with the retrospective reports being in line with previous findings based on retrospective questionnaires (and observations in the lab) that also indicate that parent-adolescent interactions in families with DEP adolescents are less supportive and more conflictual [e.g., 17 , 50 ] and lower in parental care [ 15 , 51 ]. Thus, findings on retrospective questionnaires do not necessarily match momentary assessments [ 18 ]. When adolescents are asked to report retrospectively on parenting, their memories may be negatively biased by their mood [ 9 ]. Parents of DEP adolescents have shown to be more worried about their child and question their own parenting abilities [ 52 ], which may explain differences in momentary versus retrospective parenting report of parents. Assessing parenting at the momentary level with EMA may reduce these biases.

Our findings furthermore indicate the important association between parenting and adolescent’s well-being, also for DEP adolescents. When adolescents perceived their parents as more warm or less critical during interactions they also reported more positive and less negative affect, or vice versa, supporting previous findings in community samples at the momentary [ 31 ] or daily level [ 29 , 30 ]. The momentary associations between parenting and affect in the current study did not differ between HCs and DEP adolescents. A recent study on parenting and affect during momentary parent-adolescent interactions, based on a community sample, reported similar results [ 31 ]. The abovementioned biases may play a role here as daily reports of parenting still involve some recollection, including the inherent biases, while these do not apply to momentary assessments.

Another important finding is that we found substantial variation between adolescents, indicating that the strength or direction of how warm or critical parenting is associated to adolescent affect differs between adolescents. Even within our sample of DEP adolescents, this heterogeneity was observed, showing that the association between parental warmth and criticism differed between DEP adolescents. This aligns with a previous finding also showing different patterns in adolescents who report clinically relevant depressive symptoms [ 29 ]. Studies using more person-centered and idiographic approaches are needed [ 53 ] to better understand these patterns and translate them into implications for clinical practice.

A unique feature of the current study was that we assessed parental warmth and criticism of mothers and fathers separately. Despite family system theories proposing adolescent-mother and adolescent-father dyads being distinct subsystems [ 6 , 54 ] and suggestions that parenting roles of mothers and fathers may differ [e.g., 55 ], not many studies have assessed parenting of both mothers and fathers. Our results suggest that perceived parental warmth and criticism of mothers and fathers are important for adolescent well-being. Interestingly, sensitivity analyses (in the supplementary materials) indicated that girls reported more negative and less positive affect in interactions with fathers than boys. These findings highlight the need to assess family dynamics of mothers, fathers, and adolescents together, as well as taking into account sex of adolescents.

As our study provides first insights into the momentary experiences of families with DEP adolescents by monitoring parent-adolescent interactions and includes not only adolescents’ perceptions of parenting of mothers and fathers separately but also parents’ own perception, findings are relevant for clinical practice. Since DEP adolescents do seem to benefit from parental warmth in daily life, interventions on adolescent depression may benefit from the involvement of parents, both mothers and fathers. A recent meta-analysis has shown that the involvement of parents in treatment of adolescent depression can increase the efficacy of individual CBT [ 56 ]. These family interventions could include psychoeducation to inform parents about how depression and how cognitive biases can influence adolescents’ experiences of daily life, and foster a warm family climate, limiting parental rejection, and criticism. Moreover, given the substantial variation in how parenting and adolescent affect is related and previous findings that perceptions of adolescents and parents differ [ 57 , 58 ], exploring the needs of the adolescent in treatment and discussing them with parents also seems an important ingredient. This could yield more understanding of each other’s perception and behavior as well as aligning what adolescents need or want and what parents can provide.

Some limitations should be acknowledged that may provide directions for future studies. Our sample was fairly homogenous, with the majority of adolescents and parents being born in the Netherlands. Furthermore, our sample of families with a DEP adolescent might be biased. Families who decided to participate in the study, focusing on parent-adolescent interactions, may not be families with harsh or neglecting parenting behavior, thereby resulting in an underestimation of negative parent-adolescent interactions among families with DEP adolescents. Also, even though common comorbid disorders, such as anxiety disorders, were allowed, we excluded DEP adolescents with forms of comorbid psychopathology, such as autism, that may directly influence parent-adolescent interactions. As a result, findings may deviate from naturalistic patterns in adolescents which limits interpretation and generalizability. Although future studies may strive to include a more diverse, representative sample of DEP adolescents, it is also important to mention that the inclusion of comorbid disorders may pose challenges when it comes to elucidating the specific associations with adolescent depression and parent-adolescent interactions. Moreover, although we were able to assess experiences of parent-adolescent interactions in their natural context by using EMA, it may also have resulted in collecting data of interactions about mundane matters (e.g., who is unloading the dishwasher) that may not have a large impact on adolescents’ affect. Future studies may benefit from gaining additional information about the content of the interactions. Lastly, due to limited power we have to be cautious in interpreting the findings concerning interactions with fathers. We were also not able to test the direction of effects, but focused on concurrent associations during momentary parent-adolescent interactions. Future work assessing the direction of effects could result in more specific implications for clinical practice.

Parenting has been consistently associated with adolescent depression, but most research to date has used retrospective questionnaires concerning macro-time intervals. With the use of EMA and inclusion of families with a DEP adolescent, we showed that DEP adolescents overall reported more negative and less positive affect than HCs. Generally, perceived parental warmth and criticism and affect during parent-adolescent interactions co-fluctuated. This association did not differ between DEP adolescents and HCs, even though DEP adolescents and their parents did indicate more negative parenting (e.g., less care and more overprotection) in the retrospective questionnaires. These findings indicate that adolescents generally do seem to benefit from parental warmth, while the discrepant findings also support the idea that a negativity bias may have affected the retrospective reports of parenting. Clinicians should facilitate the communication of needs and perspectives between adolescents and parents. The study further supports the idea that the extent to which parenting processes relate to adolescent affect differs per family and therefore calls for a more person-centered and idiographic approach in research to guide family interventions.

Data availability

The de-identified data, analysis scripts, and materials for this study will be made available on DataverseNL.

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Acknowledgements

We highly appreciate the effort and time devoted by participating families. Furthermore, we thank the mental health organizations that contributed to the recruitment of participants as well as students who helped recruitment and data collection.

The study was supported by a personal research grant awarded to Bernet Elzinga from the Netherlands Organization for Scientific Research (NWO-VICI; Unravelling the Impact of Emotional Maltreatment on the Developing Brain 453-15-006).

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Loes H.C. Janssen, Bart Verkuil, Lisanne A.E.M. van Houtum, Mirjam C.M. Wever, Wilma G.M. Wentholt & Bernet M. Elzinga

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L.J. participated in the design, coordination and data collection of the study, performed statistical analyses, and drafted the paper; B.V. participated in the design and coordination of the study, helped interpreting the data and writing the paper; L.v.H. participated in the design, coordination and data collection of the study; M.W. participated in the design, coordination and data collection of the study; W.W. participated in the coordination and data collection of the study; B.E. (principal investigator) secured funding, conceived the study, participated in the design and coordination of the study, helped interpreting the data and writing the paper. All authors read, reveiwed, and approved the final paper.

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Adolescents and their parents provided written active informed consent. For adolescents younger than 16 years of age, both parents with legal custody signed informed consent for participation of the adolescent.

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Janssen, L.H., Verkuil, B., van Houtum, L.A. et al. A closer look into the affect dynamics of adolescents with depression and the interactions with their parents: An ecological momentary assessment study. Eur Child Adolesc Psychiatry (2024). https://doi.org/10.1007/s00787-024-02447-1

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DOI : https://doi.org/10.1007/s00787-024-02447-1

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Are School-going Adolescents Mentally Healthy? Case Study from Sabarkantha, Gujarat, India

Tapasvi puwar.

Department of Epidemiology, Indian Institute of Public Health, Gandhinagar, Gujarat, India

Sandul Yasobant

1 Center For Development Research (ZEF), University of Bonn, NRW, Germany

Deepak Saxena

Background:.

Mental health issues becoming the global public health challenge, especially among the youth (12–24 years of age), although they are often detected later in life. In India, the adolescent population constitutes a quarter of the country's population and burden of disease varies from 9.5 to 102/1000 population. Most of the mental health disorders remain unidentified due to negligence and ignorance of multiple factors. Keeping this in mind and lack of population-based studies with good quality for guiding the mental health policies, this study aims to document the prevalence of emotional and behavioral difficulties among adolescents in Sabarkantha district of Gujarat, India.

This is a school-based cross-sectional study conducted among 11–19 years of school-going adolescents during August–September 2016. About 477 adolescents who gave consent to participate were selected from 20 randomly primary and secondary schools. A prevalidated questionnaire for sociodemographic information including global validated standard questionnaire for mental health scoring known as Strengths and Difficulties Questionnaire (SDQ) were administered and self-reported responses were documented. Statistical analysis was conducted through SPSS version 20.

Mean age of the study population was 14.2 ± 1.4 years. About 14.6% boys and 12.6% of girls had abnormal total SDQ score, while 15.3% boys and 21.9% of girls had borderline SDQ score. Thus, 70.1% of boys compared to 65.6% girls had normal SDQ score. The difference between mean (higher mean score among girls) of total SDQ score of boys and girls was statically significant at the level of P < 0.05. Major risk factors for self-reported mental health issues were illiterate mother, occupation of parents, which make them away from family during daytime, nuclear family, severe addiction to alcohol in the family, financial problem in the family, and adolescent getting daily physical punishment. One-seventh adolescents are vulnerable for mental health problems found in this study. About one-fifth adolescents have internalizing (emotional) and about one-sixth have externalizing (conduct) manifestations.

Conclusion:

There is an urgent need to address the emotional and conduct manifestation among school-going adolescents. Rashtriya Kishor Swasthya Karyakram framework needs to address these issues on priority.

I NTRODUCTION

About 14% of global burden of diseases is attributed for mental health problems in all age groups.[ 1 ] Mental health is complex and is much more than simply the absence of illness. It describes the capacity of individuals to interact with each other and their environment in a way that promotes optimal development and the use of cognitive, affective, and relational abilities, as well as overall well-being.[ 2 ] Rates of mental disorders among young people (12–24 years), ranged from 8% (in the Netherlands) to 57% (for young people receiving services in five sectors of care in San Diego, California, USA).[ 3 ] The Australian National Survey of Mental Health and Well-Being reported that at least 14% of adolescents younger than 18 years were diagnosable with a mental or substance use disorder in 12 months. The National Mental Health Survey of India 2015–2016 shows 7.3% prevalence of all psychiatric morbidity among 13–17 years age group.[ 4 ] The suffering, functional impairment, exposure to stigma and discrimination, and enhanced risk of premature death that is associated with mental disorders in adolescents has obvious public health, social, and economic significance for any society.[ 5 ]

Mental health is not just the absence of mental disorder. It is defined as a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community. Hence, mentally healthy adolescence are needed for our feature nation as well as for their own needful family life.[ 6 ] The poor mental health is strongly related to other health and development concern in adolescence people, for example, low self-confident, less socially responsible activities, committing illegal activities, and so on.[ 6 ] It is estimated that around 20% of the world's adolescents have mental health or behavioral problem.[ 7 ] About half of lifetime mental disorders begin before age 14, the prevalence of mental disorders among adolescents has increased in the past 20–30 years; the increase is attributed to disrupted family structures, growing youth unemployment, and families' unrealistic educational and vocational aspirations for their children.

In India, the adolescent population constitutes a quarter of the country's population, which is approximately 243 million, which in turn constituted 20% of the world's 1.2 billion adolescents. As per the National Mental Health Survey 2015–2016 of India, the prevalence of overall psychiatry disorder among 13–17 years age group was 7.3%, however, a systematic review indicates that prevalence of psychiatric disorders among adolescents ranged from 0.48% to 29.40%.[ 8 ] Not much importance is given in India to this branch of medical science; due to multiple factors very starting from medical cause to social causes, resulting into lack of statistical measures of prevalence and details of treatment. Most of the mental health disorders remain unidentified due to negligence and ignorance on the part of parents.[ 9 ] Proper counseling and guidance by parents play an important role in child's life. One more aspect to explore is mental status of caretaker or parents, which play an important role in their overall development.[ 10 ] Keeping this in mind, and lack of population-based studies with good quality for guiding the mental health policies, this study aims to document the prevalence of emotional and behavioral difficulties among adolescents in Sabarkantha district of Gujarat, India.

This is a cross-sectional, school-based study conducted during August–September 2016.

Study setting

The present study was conducted Sabarkantha in one of the 33 districts of Gujarat selected purposefully because of administrative feasibility. It is a diverse district in terms of composition of population with an aggregate population comprising of both tribal and nontribal population, the population of the district is 2,428,589.[ 11 ] This study has been conducted during August–September 2016.

Study sample and sampling

This study was conducted among government schools of Sabarkantha district, Gujarat. Considering the dropout rate of 20%–30%, it was also important to cover out of school adolescents. As this study used a self reported tool, most of out-of-school adolescents were unable to report the same; therefore excluded from the sample.

A representative samples of adolescents were sampled based on facts such as the reported prevalence of mental health problems among adolescents in India is 15%–20%,[ 12 ] with response rate of 80%.

The sample size for this study was calculated as 470 at 95% confidence interval level, the expected prevalence of 15%, design effect of 2 and non-response rate of 20%. Further as per, Rashtriya Kishor Swasthya Karyakram (RKSK) framework age categorization, this study recruited 235 adolescents in 11-14 years of age and another 235 adolescents in 15-19 years of age group. Considering an average class size of 30, ten schools each from primary section and secondary/higher secondary section were randomly selected from the list of schools obtained from the district education office. All the primary schools were selected from rural area as secondary/higher secondary schools were situated in the urban area. The selected class were administered with the Strengths and Difficulties Questionnaire (SDQ) for assessment of mental health.[ 12 ]

Study instrument

The self-assessment format of SDQ[ 13 ] was used to assess the mental health of the adolescents. The SDQ is a user-friendly screening questionnaire, which can be used to assess behavioral problems and mental health disorders. Goodman, Ford, Simmons, Gatward, and Meltzer reported the scale's internal reliability to be acceptable, with a Cronbach alpha coefficient of 0.73.[ 6 , 13 ] The questionnaire consists of 25 questions subdivided into five categories: Conduct; hyperactivity; peer problems; emotional; and prosocial, with five questions in each scale. Each of the categories is given a score and then summed to get a total difficulties score, except the prosocial score, which is assigned a separate score. The scores can then be used to make separate predictions for conduct–oppositional disorders, hyperactivity–inattention disorders, and anxiety–depressive disorders. The prevalidated SDQ questionnaire available in Gujarati language was used in the present study.[ 14 ] As per the suggested guidelines for SDQ, cutoff points were derived by classifying approximately 10% of the normative sample with the most extreme scores in the “abnormal” banding, the next 10% in the “borderline” banding, and the remaining 80% in the “normal” banding categories.[ 13 ]

In addition to the SDQ, relevant sociodemographic details were recorded. Perceptions of difficulties in the family domain; for example, physical punishment, parental marital discord, death of a parent, excessive alcohol/drug use by a family member, and financial difficulties in the family were documented through a prevalidated questionnaire in vernacular language.

Study analysis

Descriptive statistics analysis was carried out using SPSS version 20 (Armonk, NY, IBM Corp). For categorical variables, proportion was used to describe, whereas for continuous variables were described as mean ± standard deviation was used. Further, one sample t -test and Chi-square test were used to understand the statistical difference among the groups at level of P < 0.05.

Study ethics

Permission to conduct the study was obtained from the Institutional Ethical Committee of Indian Institute of Public Health, Gandhinagar. Verbal consent was obtained from each adolescent before administration of the study questionnaire. List of adolescents with abnormal SDQ scores will be submitted to the school management for further referral.

About 60% of adolescents were in the age group of 11–14 years and 62% of participants were boys. Mean age of the study population was 14.2 ± 1.4 years. Mean age of boys was 14.3 years while that of girls was 14.1 years. The details descriptive are shown in Table 1 .

Sociodemographic characteristics of adolescents a in Sabarkantha, Gujarat

About 9% of fathers of the study participants were unemployed, while majority of them work as labor. Over 40% of mothers of participants were homemakers. Out of the total samples included in the present study, three participants also reported about demise of their parent, six reported demise of mother while, and 16 reported loss of father. Eleven (2.3%) participants reported that their parents were not staying together (separated and divorced). Around than 7% boys and 8.2% girls reported a history of excessive alcohol consumption by father or grandfather. On inquiring about the issues pertaining to finance, around 11% boys and 13% girls reported financial problems; faced by respective families. Out of all 72% of participants believed that physical punishment is necessary if children are not studying properly on the contrary, only 5.6% participants reported receipt of physical punishment daily.

The present study utilized SDQ, to assess various aspects of mental health of adolescents. About 14.6% of boys and 12.6% of girls had an abnormal total SDQ score and 15.3% of boys and 21.9% of girls had borderline SDQ score. Overall 70.1% of boys and 65.6% of girls had normal SDQ score. The difference between mean (higher mean score among girls) of total SDQ score of boys and girls was statically significant at the level of P < 0.05.

In general, SDQ is divided into five subcategories as shown in Table 2 . According to that, almost 40% girls had abnormal or borderline Emotional Problem Score (EPS), compared to <30% of boys. The difference in mean EPS among boys and girls is statistically significant. Almost 38% of boys and 33% of girls had abnormal or borderline Peer Problem Score (PPS). However, this observed difference is not statistically significant. Most importantly, girls have higher mean SDQ score compared to boys in EPS, Hypersensitivity Score (HS), Total SDQ score, and Prosocial Score and all these differences are statistically significant. Boys had higher mean score in conduct problem score and PPS; however, these differences were not statistically significant. On application of hierarchical regression model, a statistically significant difference in mean total SDQ score was observed for gender, mother's education, occupation of mother, occupation of father, type of family, living in the hostel (away from family), severe addiction to alcohol in the family, receiving physical punishment daily, and having some financial problem in the family.

Strengths and Difficulties Questionnaire score and its differential components in relation to gender of adolescents of Sabarkantha, Gujarat

D ISCUSSION

The World Health Organization defines mental health as a “state of well-being whereby individuals recognize their abilities, are able to cope with the normal stresses of life, work productively and fruitfully, and make a contribution to their communities.” Applying such adult-based definitions to adolescents and identifying mental health problems in young people can be difficult, given the substantial changes in behavior, thinking capacities, and identity that occurs during the teenage years. The impact of changing youth subcultures on behavior and priorities can also make it difficult to define mental health and mental health problems in adolescents. Although mental disorders reflect psychiatric disturbance, adolescents may be affected more broadly by mental health problems. These include various difficulties and burdens that interfere with adolescent development and adversely affect the quality of life emotionally, socially, and vocationally. There are limitations of available community-based status of mental health among adolescent, published studies largely focus on measures of individual disorder and dysfunction, without consideration of contextual factors that shape mental health and well-being. There are available evidence that have identified contextual factors that place adolescents at greater risk of mental health problems.[ 15 ] The present case study was undertaken to document mental health vulnerability of school-going adolescent in rural Gujarat. The study reveals that 14% of the study population is vulnerable for mental health problems. More than 18% of adolescents have internalizing (emotional) and more than 16% have externalizing (conduct) manifestations. However, only 3% had hyperactivity manifestations as per the study. Bhola et al . reported in a study using SDQ tool among preuniversity college students at Bengaluru, reported 10.1% of adolescents had total difficulty levels in the abnormal range, with 9% at risk for emotional symptoms, 13% for conduct problems, 12.6% for hyperactivity/inattention, and 9.4% for peer problems.[ 16 ] The observed difference between two studies may be due to difference in the age of the study participants where the mean age of study population was 16.4 years compared to 14.2 years in the present study. The same study identified gender differences in patterns of psychopathology among adolescents. Along with other studies using the SDQ,[ 17 , 18 , 19 , 20 ] emotional symptoms were predominant among girls and peer problems among boys. This study found out same, but the observed difference for emotional symptoms was statistically significant while observed difference in peer problems was not statistically significant. We also observed that girls were more social compared to boys. Kharod et al . reported in a study in rural Gujarat, 33% adolescents with abnormal SDQ scores.[ 21 ] The highest abnormal score was reported for peer problem scores in the study and lowest among the Prosocial Score category.

Interestingly, in contrast to other research, the findings from Bhola et al . study and the present study showed that there was no gender difference for conduct problems and hyperactivity problems. This may be due to narrowing gender gap for these problems. This suggests gender-sensitive modification should be made in school- or college-level adolescent mental health programs. The present study also showed a significant higher total difficulty scores where mother is illiterate, occupation of parents which make them away from family during daytime, nuclear family, severe addiction to alcohol in the family, financial problem in the family, and adolescent getting daily physical punishment. However, they were not the predictor of low SDQ score as suggested by very low R 2 value of regression models tried in the study which indicates the need of larger scale study to predict such vulnerabilities. Although these factors suggest vulnerability for mental health problems in adolescents, this is worth to explore with further research studies to prevent the risks in this age group. The existing guidelines of RKSK do talk about the mental issues; however, it does not suggest methods on how to assess the status of mental health among the adolescent. Limitation of the present study is that it has used self-reported SDQ screening and not matched it with parents or teacher version as suggested by studies using SDQ beyond Europe.[ 22 ] Furthermore, the study could not examine adolescents with abnormal scores with other diagnostic tools used in psychiatry.

C ONCLUSION

The present study documents about one-seventh of the adolescents were vulnerable for mental health issues. About one-fifth adolescents have internalizing (emotional) and about one-sixth have externalizing (conduct) manifestations; however, very few (3%) had hyperactivity manifestations. Most common risk factors for self-reported mental health issues were illiterate mother, occupation of parents, away from family during daytime, nuclear family, severe addiction to alcohol in the family, financial problem in the family, and adolescent getting daily physical punishment. It is recommended based on the study to use the SDQ screening tool in Gujarati for screening adolescents in Gujarat and adolescents with abnormal scores should be referred to psychiatrist and counselors at Adolescent Friendly Health Clinics for further diagnosis and treatment if required. SDQ tool can be used in screening for adolescents under Rashtriya Bal Swasthya Karyakram to strengthen the focus on the mental health aspect of the program and linking referral of adolescents with low SDQ scores to adolescent-friendly health clinics for further steps.

Financial support and sponsorship

This study was funded by John D. and Catherine T. MacArthur Foundation. Funders have no role in study designing and findings from this research.

Conflicts of interest

There are no conflicts of interest.

Acknowledgment

The authors are thankful to the Government of Gujarat, Department of Health and Family Welfare and also to the school staff for providing constant support for this study and to students for participating in this valuable research.

R EFERENCES

• Open access
• Published: 21 May 2024

Novel CHATogether family-centered mental health care in the post-pandemic era: a pilot case and evaluation

• Caylan J. Bookman 1   na1 ,
• Julio C. Nunes 1   na1 ,
• Nealie T. Ngo 2 ,
• Naomi Kunstler Twickler 3 ,
• Tammy S. Smith 3 ,
• Ruby Lekwauwa 1 , 3 &
• Eunice Y. Yuen 1 , 3 , 4 , 5  

Child and Adolescent Psychiatry and Mental Health volume  18 , Article number:  57 ( 2024 ) Cite this article

Metrics details

The COVID-19 pandemic impacted children, adolescents, and their families, with significant psychosocial consequences. The prevalence of anxiety, depression, and self-injurious behaviors increased in our youth, as well as the number of suicide attempts and hospitalizations related to suicidal ideation. Additionally, parents’ mental health saw increasing rates of depression, irritability, and alcohol use combined with worsening family function, child-parent connectedness, positive family expressiveness, and increases in family conflict. In light of these statistics, we created CHATogether (Compassionate Home, Action Together), a pilot family-centered intervention using multi-faceted psychotherapeutic approaches to improve familial communication and relational health between adolescents and their parents. This paper discusses the implementation of the CHATogether intervention at the Adolescent Intensive Outpatient Program (IOP), providing an example of the intervention through an in-depth pilot case, and evaluation of the program’s acceptability and feasibility.

This paper describes a case in detail and evaluation from a total of 30 families that completed CHATogether in the initial pilot. Each family had 4–6 one-hour CHATogether sessions during their 6-week treatment course at the IOP. Before and after CHATogether , adolescents and their parents separately completed a questionnaire designed to explore their perceived family conflicts. After completion of the program, participants completed a brief quality improvement survey to assess their overall experience with CHATogether . In the reported case, the family completed Patient-Reported Outcomes Measurement Information System (PROMIS) depressive and anxiety symptoms scales, Conflict Behavior Questionnaires (CBQ), 9-item Concise Health Risk Tracking Self-Report (CHRT-SR9), and help-seeking attitude from adults during distress and suicide concerns.

The pilot case showed a trend of improvement in reported depressive and anxiety symptoms, child-parent conflicts, subfactors of suicide risk including pessimism, helplessness, and despair, help-seeking acceptability from parents for suicide concerns, and the establishment of individualized family relationship goals. Preliminary feedback from participating families demonstrated positive effects on intra-family communication and improvement in the overall family dynamic. Adolescents ( n  = 30/30) and their parents ( n  = 30/30) rated “strongly agree” or “agree” that their families had benefited from CHATogether and welcomed participation in future program development.

This study presents CHATogether as a novel family-centered intervention to address post-pandemic family mental health stress, especially when a family system was disrupted and negatively affected the mental health of children and adolescents. The intervention facilitated positive child-parent communication on a variety of topics, through tools such as emotional expression and help-seeking behavior. The reported pilot case and evaluation suggested CHATogether ’s acceptability and feasibility in a clinical context. We also provided quality improvement feedback to guide future studies in establishing the efficacy of CHATogether and other similar models of clinical family interventions.

Introduction

Since the COVID-19 pandemic, both national and regional organizations have highlighted the significant increase in mental health challenges faced by children, adolescents, and their families. As a result, the American Academy of Child and Adolescent Psychiatry, in partnership with the American Academy of Pediatrics and the Children’s Hospital Association declared a national emergency in children’s mental health in 2021 [ 1 ].

This mental health crisis has been due in part to the stress and disruption within family systems, as well as the relative isolation caused by the various constraints of the pandemic. These factors resulted in a significant increase in the utilization of children and adolescent mental health services [ 2 , 3 ]. The pandemic left a notable negative footprint on societal structures and dynamics, putting increased pressure and strain on individual families [ 4 , 5 , 6 ]. Many community support systems such as schools, places of worship, and recreational spaces were abruptly closed due to the pandemic, leaving families without vital community resources. The pandemic exacerbated existing inequalities for families with ethnic minority and low socioeconomic backgrounds [ 7 ]. Taken together, these factors disrupted parental reflective functioning and adaptive family communication [ 8 ]. The pandemic forcefully imposed a new norm – social isolation, boredom, elevated parental scrutiny, and the loss of independence – all of which negatively altered how a child or teen reacted to their parents [ 4 , 5 , 6 ].

Furthermore, there were notable changes in children’s and adolescents’ behaviors, such as an increase in difficulty concentrating, lower frustration tolerance, and a lower threshold for “general discomfort” [ 9 , 10 ]. Parents stepped into multiple new roles at home, attempting to meet the increased needs of their children. Simultaneously, they worried about health and finances, leading to increased frustration and authoritarian parenting, decreased engagement with their children, and ability to reason and self-regulate [ 4 , 11 ].

In 2019, we established CHATogether ( C ompassionate H ome, A ction T ogether), a digital community-based mental health program tailored for children, adolescents, and their families. CHATogether included different creative modalities to address cross-cultural and cross-generational needs while also promoting improved mental health among adolescents and their families. The program consisted of six core arms that include: digital interactive theater, public mental health education, research, peer support and community outreach, collaboration, and mentorship. These arms aimed to provide a feasible and successful family wellness initiative in response to the COVID-19 pandemic [ 12 ]. Through this community effort, we have witnessed the dire clinical need to address familial mental health as a one-unit system during the post-pandemic era.

In 2022, we have adapted and implemented the clinical CHATogether program at the adolescent Intensive Outpatient Program (IOP), a subacute level of mental health care that supports both adolescent patients and their families. During the IOP intake assessment, adolescents and families were routinely asked about their perception of parenting practices. Our clinical impression suggested that most families perceived each other to have challenges in at least one or more domains of effective parenting (e.g., consistency, supervision/monitoring). Moreover, a significant discrepancy between the adolescent’s and parent’s perspectives regarding these domains implicated opportunities to bridge this unmet clinical gap and improve the overall adolescent-parent dyadic functioning. This pilot evaluation aimed to (1) report on the CHATogether family-centered intervention, (2) provide a pilot case with preliminary data to exemplify how the intervention works, and (3) evaluate the acceptability and feasibility from a total of 30 families who completed CHATogether in the adolescent IOP during the post-pandemic era.

Theoretical context of  CHATogether family intervention

CHATogether is based upon a psychodynamic, bio-psycho-social model that focuses interventions on the family/social systems aspect of this dynamically interactive tripartite model. It incorporates psychotherapeutic elements from drama therapy, cognitive behavioral therapy (CBT), and psychologically focused therapies in ways that improve family relational health and communication, and adolescent mental health. The program facilitated and guided family members’ expression of unconscious conflicts, feelings, fears, and imaginings through engaging in theater skits and role-playing [ 13 , 14 , 15 ]. Drama therapy techniques allowed participants to project their internal feelings and conflicts onto skit characters [ 16 , 17 , 18 ]. As in psychodynamic play therapy, participants could experiment within the safety of displacement that theater provides [ 19 , 20 ]. Previously intolerable fears as well as emotionally charged feelings would be identified, become available for collaborative reflection, and lead to eventual conflict resolution. Drawing upon aspects from psychodynamic, CBT, and drama therapy, the clinician helped families develop better adaptive, healthier patterns of communicating feelings and behaviors as illustrated by the skits [ 21 , 22 ]. Additionally, the clinician made drama-to-life connections whereby family participants could apply what they learned to improve communication patterns amongst themselves.

CHATogether has emphasized a whole family approach [ 23 , 24 ]. Thus, it could be a therapeutic process that addresses relational conflicts within the family system, the third component of the biological-psychological-social/family model, in addition to the biological and psychological treatments the adolescents typically receive in IOP. Traditional family therapies could have low adherence due to factors such as families’ resistance to engage in treatment that require multiple sessions over many months for meaningful change to be accomplished [ 25 , 26 ]. Compared to the inpatient services or outpatient clinics, the IOP has been the ideal setting for implementing high-impact, brief family interventions given the acuity and need of the population as well as the time frame and highly structured nature of IOP treatment [ 27 ].

Participants recruitment and selection criteria

A total of 30 families with adolescents aged 12–17 years old were included in this pilot assessment of the CHATogether program (Table  1 ). The 30 participating families included teens ( n  = 30), who were accompanied by both parents ( n  = 14), mother only ( n  = 10), father only ( n  = 4), or other caregivers ( n  = 2). All adolescents were existing patients enrolled in Yale New Haven Hospital (YNHH) Adolescent Outpatient Behavioral Services from October 2022 to December 2023. Patients attended the conventional 6-week general mental health intensive outpatient program (IOP) track, which included 3 hours per day, 4 days per week of after-school group therapy, weekly medication management, and family case management for discharge planning. The goals of the general IOP emphasized the stabilization of psychiatric symptoms and safety through treatments such as medication management and learning coping strategies from group therapy. The IOP treatment patients were referred from the YNHH inpatient adolescent units, emergency department, Yale Child Study Center, and local outpatient clinics in Connecticut.

Regarding inclusion and exclusion criteria, this study included patients who have significant family relational conflicts that may hinder the conventional IOP treatment. This IOP does not typically accept patients with high acuity psychiatric conditions, including those with significant active psychosis, substance intoxication/withdrawal, active eating disorder, delirium, or developmental delay with significant cognitive impairments as these conditions can impede the ability of adolescents to fully engage in treatments. In the study, CHATogether participating adolescents and their parents/caregivers received additional treatments through at least 4–6 one-hour family sessions during the 6-week IOP. Parental consent and adolescent assent were discussed at least one week prior to the intervention.

CHATogether family session protocol

The program was delivered in-person, virtually, or using a hybrid format, depending on the parents/caregivers’ availability. A total of 3 clinicians delivered the intervention. Pre- and post-session questionnaires were individually completed by adolescents and their parents/caregivers in the first and last session of the CHATogether program.

Partly adopted from the Family Relational Assessment Protocol (FRAP) [ 28 ], the questionnaires included family relationship goals, major conflicts in the child-parent dyads, major conflicts between the parents, family losses, and major areas to change. The design encouraged the families to revisit the questions and troubleshoot together with the newfound strategies and communication (Table 2 ). The first CHATogether family session consisted of guiding the family to view a three-part theater skit in the following order: (1) problematic scenario; (2) pause and moderation; and (3) alternative scenario ( https://www.youtube.com/watch?v=6Rx7D4x1nLY ).

Problematic scenario: “A Christmas Carol epiphany in child-parent relation”

Mentalization is an essential capacity to envision the state of mind in self or others, which involves understanding and anticipating each other perspectives through a lens of curiosity and without judgment [ 8 , 29 , 30 ]. According to this theory, mentalization not only allows parents to understand their child’s behaviors and underlying feelings, but also helps parents respond to the child’s emotional needs sensitively, and ultimately improve the child’s affect regulation [ 31 , 32 ]. To introduce the concept of mentalization, the family watched the skit video, “ Parents Got All the Solutions ”. Prior to viewing the skit, parents or caregivers were prompted to mentalize the teens’ perspective in the skit, whereas adolescents were asked to mentalize the parents’ challenges in the skit.

A high school teen is trying to communicate to his father about his feelings of depression and thoughts of suicide. Being a single parent, the father in the skit has worked all day and is taking care of three children. The father is terrified because he has found several empty pill bottles in his teenager’s room and is now persistently offering “solutions” in an attempt to “fix” his son’s mental health.

Pause and moderation: learn, share, and reflect

The clinician guided the family to identify unhelpful examples of communication in the problematic scenario. In the initial half of the moderation, therapeutic interruption and facilitation were employed by the clinician to help the family focus on discussing the skit instead of directly jumping into their family conflicts. First, verbal and nonverbal communication including language, word choice, tone, body gestures, and any expressive emotion that may impede a caring conversation were discussed. Second, the clinician pointed out parental invalidation in the video and stressed the importance of validating a teenager’s emotions before offering solutions or guidance. Third, the clinician introduced the concept of “listening to understand” rather than reacting to a conflict. Additional points for discussion included the acting teenagers’ attitude in the skit, for example, their tone of voice, frustration, lack of patience, and how these can negatively impact the parents’ understanding of the situation. Lastly, the clinician guided the family to relate their own experiences to the themes illustrated in the skit, allowing the family to draw parallels between the problematic communication styles in the video to ones possibly in their own family.

Alternative scenario: establish commitment, communication exercises, and follow up

The alternative scenario of the skit “ Parents Got All the Solutions ” displayed the situation with more effective communication strategies. The family was prompted to compare and contrast the two scenarios. The clinician guided the family to reflect upon how they can practice healthy communication in their home life. Given its emotional intensity, the first CHATogether family session fostered the best opportunity for parents and their children to emotionally reconnect and establish a mutual commitment to positive change within the family. The session ended with facilitated cohesion where the clinician encouraged each family member to share their love and gratitude to each other. The family session concluded with the homework (a two-minute communication exercise every day) to be completed by the next session: (1) adolescents and parents commit a time to talk each day without stress and distraction; (2) each side takes turns to talk about their day and openly share their feelings without interruption for 2 min; (3) the listener practices mentalization while listening attentively and validating the speaker’s experiences afterward.

In the subsequent sessions, the family reflected on their communication exercises and the concepts introduced in the first session, leading to a shared learning experience. Each session also included psychoeducation on child-parent communication skills, signs and symptoms of mental health conditions illustrated from the initial skit, as well as a review of homework on skills/concepts discussed from the previous sessions. Moreover, the clinician emphasized any emerging relational conflicts in the past week and guided the family to practice their newfound communication and coping skills to reflect on or resolve the conflicts. If applicable, the clinician presented other skits involving different themes that followed a similar sequence to those described in the first session.

Data collection

Institutional review board approval from the Yale Human Investigations Committee was obtained (Protocol #2000034837). Families consented to study participation prior to the beginning of the survey. The study was entirely voluntary, and the families were welcomed to receive CHATogether treatment regardless of their participation in the study. In the case vignette, additional written consent from the family was obtained, and the case was de-identified with modifications to protect the patient’s and family’s privacy.

To measure the program’s overall acceptability and feasibility in all participating families, a 6-item-survey 5-point Likert scale (“strongly disagree” to “strongly agree”) was delivered using the HIPAA-secured Yale Qualtrics system in the last CHATogether family session. Each question also included open-ended qualitative text boxes for participants to voluntarily elaborate on their answers (Table 3 ).

The study has been collecting validated psychometric measures for the study’s next phase since December 2023. Although not a significant sample size for statistical analysis in this paper, the existing families showed a similar trend to that described in Table  4 . In the pilot case and Table  4 , the teen filled out the following outcome measures in the first and the last CHATogether sessions. Measurements included Patient-Reported Outcomes Measurement Information System (PROMIS) depression and anxiety symptoms scales [ 33 , 34 ], Conflict Behavior Questionnaires (CBQ) [ 35 , 36 ], 9-item Concise Health Risk Tracking-Self-Report (CHRT-SR9) [ 37 ], and seeking adult help for distress and suicide concerns [ 38 , 39 ]. The help-seeking attitude measurements included a three-part adapted version from Schmeelk-Cone et al. to detect (1) teens’ help-seeking acceptability from parents, (2) adult help for suicidal youth, and (3) reject codes of silence. The last item measured teens’ attitudes to resist the secrecy about their peers’ suicide concerns. A higher score indicated that the teen has a preference to reach out to an adult for help [ 38 ]. The case participant’s parents also completed the parent version of PROMIS and CBQ.

Samantha’s case

Samantha was a 16-year-old girl who struggled with major depressive disorder (MDD), generalized anxiety disorder (GAD), and suicidal ideation. She never felt safe to verbalize her emotions or suicidal thoughts due to family conflicts and perceived judgment of mental illness. Her parents felt that Samantha’s suicidal thoughts were “wrong” and “unnecessary.” They also invalidated Samantha’s sadness from bullying she received at school which involved girl-to-girl relational aggression [ 40 , 41 ]. Gradually, she secretly turned to online relationships where she was asked to share nude pictures with strangers. Several online friends proposed a suicide pact at a time when Samantha already felt emotionally distressed with nowhere to turn. Her parents never knew about these dynamics until Samantha disclosed it to her therapist, leading to her first psychiatric hospitalization.

After being discharged from the psychiatric hospital, Samantha continued to stabilize at the IOP. She either suppressed her emotions or quickly became dysregulated when her parents confronted her phone use. Her mind was occupied with dark thoughts that she did not deserve to live or that she needed to punish herself by self-harming. Similarly to before her hospitalization, none of these thoughts or actions were shared with her parents, as she believed this would result in being yelled at and criticized. She reported a complete distrust in her ability to keep herself safe. The family conflicts once led to a report to Child Protective Services concerning harsh disciplinary practices.

The course of Samantha’s  CHATogether  treatment

In session 1, Samantha and her parents were shown the skit video, “ Parents Got All the Solutions ”, as described in the methods. Each member of Samantha’s family committed to make changes in alignment with the best interests of Samantha. Facilitating cohesion within the family, they were asked to share their love and gratitude at the end of the session. They then went home with simple two-minute daily exercises of active listening and mentalization without interruption. The clinician assigned the family similar exercises after each session as described in the method session.

In session 2, the clinician first reflected on the communication exercises and then began to address the pertinent areas of child-parent conflicts within the family as identified in Table 2 . Samantha’s mother was concerned because Samantha spent too much time in her room on her phone with online strangers. Taking extreme safety measures, the mother took away Samantha’s phone, restricted all her social contacts, and ultimately did not allow her to leave home alone. Conversely, Samantha felt online friends mattered to her mental health, and was frustrated by her parents’ absolute control and lack of trust. This was an emotionally charged session that required the clinician to role-play in order to model the concepts of mentalization and validation. This demonstrated a more supportive and productive way to navigate conflicts. The clinician demonstrated possible conversing scripts for parents when Samantha expressed sadness from having no friends and being bullied at school. For example, the clinician instructed parents, “Let’s take Samantha’s perspectives by curiously envisioning her feelings, intentions, and behaviors without judgment or imposing parental assumptions (mentalization)”. “It must be really hard to face those mean bullies at school” (validation and empathy). “How can I support you to meet new friends while making sure that you are safe?” (collaborate to meet both Samantha’s and parents’ needs).

In session 3, as the clinician reviewed the communication exercises, Samantha and her parents started to show mutual reflective capacity and acknowledged that everyone needed to empathize and compromise to become a functioning family. Samantha was willing to recognize her parents’ safety concerns were valid but wanted her parents to listen to her needs without getting angry. The parents recognized that Samantha needed to make friends and develop sound judgment before she would emerge into young adulthood. They started to understand Samantha’s suffering from mental illness and began to meet her emotional needs with less judgment and criticism. However, in areas of phone use, Samantha’s mother continued to emphasize rule-following responsibilities repeatedly, which once led to disagreement between the parents. The clinician then developed a contract with measurable items for the family to collaborate on phone use. For example, the parents practiced one-time questioning Samantha’s online friend on a given day, while Samantha proactively communicated with her parents about her friend such as his or her name, age, and location to ensure safety. By the end of the session, the family was able to articulate and elaborate on their gratitude to each other.

In sessions 4 and 5, Samantha’s mother gradually realized that she was fearful of letting Samantha make friends online due to the mother’s childhood trauma. To meet Samantha and her family’s needs, a video skit on “ Intergenerational Trauma: The Shark Music ” was shown. The clinician reflected on how intergenerational trauma can play a role in one’s perception of fear and safety, and how that may impact teen-parent communication and relational health. Samantha and her parents were surprised but also relieved by this deep conversation that could ever occur within a family, and how much they were able to view from each other’s perspectives. In the last session of CHATogether , Samantha and her mother conducted the post-session questions, reflected on their progress during the program, and discussed goals for their family. Towards the end of the treatment, Samantha developed a newfound interest in music, resulting in a shared interest between Samantha and her parents as they began participating in family music lessons together. Ultimately, Samantha returned to school and made new friends in the school’s music band.

As shown in the individualized family questionnaires (Table 2 ), Samantha and her parents’ relational health improved throughout 6 CHATogether family sessions. Samantha’s parents demonstrated a great improvement in their reflective functioning and began communicating with Samantha with curiosity instead of judgment. Parents were able to learn how to regulate their emotional stress while mentalizing Samantha’s emotional needs. Consistent with the trend of these narrative data in Table 2 , Samantha’s and her parents’ scores improved across measures (Table  4 ). PROMIS T-scores decreased to the None to Slight range across informants by the post assessment. The family was able to communicate and develop a shared plan on phone use, engagement in healthy social relationships, and communication when a psychiatric crisis arises, as suggested in the reduction of CBQ reported by Samantha and her parents. Samantha’s CHRT-SR9 reduced, especially in the subfactors most closely associated with suicide risk [ 37 ], including pessimism, helplessness, and despair. There was no obvious change in Samantha’s attitude toward seeking help from a general adult during distress and suicide concerns (Item 2) but she had an increase in help-seeking acceptability from her parents (Item 1). Lastly, Samantha had no change in her attitude that youth struggling with suicide should not be left alone and should seek adult help even if a suicidal youth asked her to keep it secret (Item 3).

CHATogether ’s preliminary feedback, acceptability, and feasibility

As shown in Table 3 , preliminary feedback suggested that CHATogether is an acceptable and feasible intervention when implemented in family sessions with adolescents enrolled in the subacute IOP settings. Participating families ( n  = 30/30) strongly agreed or agreed that they were satisfied with the CHATogether treatment and that their communication and overall family functioning improved. Most of the participants felt that the program fit well with their existing IOP treatment, was convenient for their schedule, and would recommend it to others. There were 3 families who completed the program but did not follow up on the post-session questions after multiple contact attempts. There were 2 recruited families that did not complete the program as the patients were sent back to the inpatient unit due to the severity of their mental health. They did not return to IOP services after discharging from inpatients. Since we did not collect a complete set of data, these 5 families were excluded from the n  = 30.

The COVID-19 pandemic has had serious mental health effects on children, parents, and the functioning of the family unit. The case of Samantha and preliminary feedback data from participating families indicated that CHATogether is an acceptable and feasible therapeutic intervention for adolescents who are experiencing significant family relational conflict and impaired communication in ways that contribute to symptoms and limit adaptive help-seeking behaviors. The pilot clinical impressions suggested that CHATogether can lead to more compassionate child-parent communication, an overall improvement in an individual patient’s functioning, and progress towards a family’s individual relationship goals. Our data also suggested that CHATogether is an acceptable and feasible pilot program to be implemented in the IOP systems using technology to allow in-person, virtual, and hybrid deliveries of care.

A conceptualization of why  CHATogether  works

The CHATogether family-centered model has been a unique one. Adopted in part from the Brazilian playwright Augusto Boal’s “Theatre of the Oppressed” (TOp) from the 1970s [ 42 , 43 ], it aimed to promote a non-hierarchical dialogue among participants to guide imagination-based changes and collective actions in a conflictual situation [ 44 ]. By projecting family conflicts onto characters in a theater skit, one possible explanation for the therapeutic effect of CHATogether is that it symbolically displaced participants’ unconscious internal world onto the tangible yet distant theater skits [ 13 , 14 , 15 ]. Such a modality, much like children’s play, may provide a safe means for displacing feelings, impulses, and imaginings too strong or potentially overwhelming to address directly [ 19 , 20 ]. This approach could also provide participants with a window of access to unconscious and heavily defended emotions that become more consciously tolerable in the safety of displacement. Maladaptive defensive ways of coping with powerful emotions were identified and understood in ways that enhance perspective taking, effective communication, and possibilities for change. The case demonstrated how the clinician’s moderation facilitates a therapeutic process that leads to an ‘internal switch’ whereby parents experience the power of this “Aha! moment” of self-realization. Parents in the program identified this as one of the most compelling moments in the therapeutic process. Such pivotal points allowed parents to understand their children through different perspectives.

Once restored to a state of greater emotional stability, meaningful conversation between family members became possible. Another possible therapeutic benefit of CHATogether could be that the program coached parents in mindfulness practice [ 45 , 46 ] which helped in reducing emotional reactivity and maladaptive, rigid defensiveness [ 31 ]. Ego strengths including self-observation were enhanced, identified, and supported. Some parents suggested that the skills they learned helped them remain attuned to their child’s emotional needs even while very frustrated. Most importantly, clinician moderation of the CHATogether program may enhance the process of mentalization [ 8 , 29 , 30 , 31 , 32 ], facilitating mutual reflective functioning within the family. In the case of Samantha and her parents, they mentalized the experiences of the skit characters, mutually empathized with the characters’ challenges, and used this common ground and their newfound skills to improve their relationship. Such an approach could allow for the learning of multiple ways to better cope with their hyper- or hypo-aroused state of mind. Samantha and her parents were able to enhance their reflective functioning through cognitive curiosity and flexibility in their conversations with each other [ 31 ]. The program may improve reflective capacity not only between the teens and parents but also the relational health between caregivers, as Samantha’s parents reported improved communication when approaching parenting that resulted in less conflicts.

Each CHATogether session included a psycho-educational component illustrated by the contents illustrated in the skit. Integrating all three components of the bio-psycho-social model of mental health assessment and treatment, it was designed to address child-parent communication skills, signs and symptoms of psychological distress and disorder, as well as medication and its management. The clinician guided Samantha and her parents to identify the patterns of feelings, thoughts, and behaviors when comparing the problematic vs. alternative scenarios. Samantha’s family found that viewing, role-playing, and practicing homework exercises illustrated in the two skit videos, was especially useful in communicating better with Samantha [ 21 , 22 ]. The measurement-based approach in tracking pre- vs. post-session rating scales also provided objective data to reflect on the family’s progress and highlight validations of everyone’s efforts in the treatment. Over time, CHATogether not only provided Samantha and her parents with coping skills and more adaptive defenses, but it also nurtured shared growth, love, and partnerships that were collaborative rather than adversarial in the face of difficult feelings. CHATogether ’s therapeutic potential could be consistent with the family resilience framework which suggests the importance of shared belief systems in (1) meaning-making processes; (2) a positive, hopeful outlook, and active agency; and (3) transcendent values and spiritual moorings for inspiration, transformation, and positive growth [ 47 , 48 , 49 ]. This framework emphasized strengths and resiliencies within the broader context of family relationships and community resources in helping family members adjust to stress, and cope with loss. Throughout the CHATogether intervention, the family was asked to make a strong commitment to change, while aiming towards identified and shared family relationship goals. The program provided each family member with a means of processing their fears in ways other than unconscious ‘fight-flight’ patterns. It supported ways of managing more consciously experienced fears and grief, with less attacking of self or others. The CHATogether program may ultimately help to build family members’ capacities for compassion, hope, and resilience, thereby strengthening the family as a well-functioning unit.

Family mental health: treating the whole family system

Cross-sectional research suggested that parents with self-reported higher stress levels had fewer positive parenting practices during the pandemic [ 4 , 5 , 6 , 50 ]. Additionally, there could be the longer-term issue of family “scarring,” defined as prolonged problems in family relationships even after protective factors have been activated [ 51 ]. COVID-19 has led to an exacerbation of child-parent conflicts and household chaos [ 52 ]. Families have had an urgent need for interventions that can provide comprehensive support during and after times of crisis. CHATogether is a unique intervention in that it treats the whole family as the ‘patient’, and as one of three systems dynamically intertwined in the bio-psycho-social/family/community psychodynamic model of human development. Under this concept, the family should be the basis for health which catalyzes changes to improve the entire family and downstream individual functioning [ 23 , 24 ]. At the systemic level, treating the family wholistically can also be helpful in light of workforce shortages to adequately meet the rising demands of children’s mental health services [ 53 , 54 ].

The strength of the CHATogether program may be that it actively identified those factors that interfere with family functioning while therapeutically facilitating the love, cohesion, and deep devotion to one another that is the foundation of any family unit. This intervention could be especially vital for children’s and adolescents’ mental health when family function is compromised due to forces disrupting the security of jobs, food, finances, and health during the pandemic. With its focus on a deep respect for differing perspectives, CHATogether could calibrate the power dynamics within families to be more equitable and holistic.

Limitations, challenges, and future directions

The current study was a pilot trial of an innovative family-centered treatment. We have illustrated a representative pilot case with supporting preliminary data and the acceptability and feasibility from a total of 30 families voluntarily enrolled in the CHATogether program implemented at the IOP level of care. Most patients were recruited within the state of Connecticut. There are several limitations and challenges that help guide future directions. The patient/family population in the current study may not be generalizable to larger populations. This preliminary study did not answer whether the improvement of child-parent communication was solely due to participation of CHATogether and/or in part from the conventional IOP treatment that does not include this family intervention component. Sustained impacts on the participating families beyond the 4–6 sessions of CHATogether were also unknown. Moreover, we did not collect more extensive qualitative data such as focus group and/or individual interviews, which would reveal more narrative information about the feedback.

Future studies should include randomized, mixed-method, and longitudinal investigations from larger and more diverse populations to compare CHATogether and conventional IOP vs. conventional IOP alone. Such a study could examine whether family-centered treatment may provide additional benefits in adolescents compared to those receiving biological- and psychological-based treatment. The inclusion criteria for the current study included patients who demonstrated family conflicts but were not specific to a diagnosis, symptoms, or level of functioning upon entry into IOP treatment. By collecting more data with validated psychometric measures, future studies for the CHATogether program as a family intervention model could examine whether participation in the program can contribute to the reduction of clinical symptoms and suicide in specific psychiatric conditions such as major depressive disorder and generalized anxiety disorder. The Inclusion of the established measures in reflective functioning within a family would be particularly valuable in the next stage of study [ 55 ]. In addition, reproducibility and scalability to deliver CHATogether could be a challenge. In this study, we have not measured the perception of the intervention’s acceptability and feasibility from the clinicians, but the intervention team meets monthly to collect verbal feedback as the program expands. We have produced tutorial videos and a standardized protocol to minimize inter-clinician discrepancy, and we also have plans to establish a nationwide webinar training series to elevate the program’s scalability. The program has been developing a digital library to provide access to CHATogether skit videos and training manuals to the trained clinicians.

While preparing this manuscript, we produced more skit videos based on varying child, adolescent, and family mental health topics. Future videos need to incorporate social determinants of health reflected in the diverse racial, ethnic, religious, and economic backgrounds of participating families. Translations with subtitles including Spanish and Chinese could be important. CHATogether skits were created based on diverse family scenarios with consultations from patients, their families, and the treatment team. The skit simulated yet may not be fully applicable to families’ real-life scenarios. Moreover, the “problematic scenario” from the intervention may re-expose unpleasant memories in patients and families, and thus anticipatory guidance and post-session emotional support would be essential. The intervention did not fully adapt to children and adolescents who are shy, have limited verbal communication, or feel more secure in the isolated digital existence. To this end, artificial intelligence with graphic illustrations, such as Avatar Assistant , Digital Twins , and Virtual Self , would be helpful venues for neurodivergent youth and their parents to better engage, identify, and express the emotions being depicted in the CHATogether skits [ 56 , 57 , 58 , 59 ]. Although it warrants thoughtful development in the future, AI-guided CHATogether chatbots could be a scalable solution for families with limited access to the intervention. Moreover, adapting CHATogether in a social media format like that of TikTok and Instagram could be developmentally palatable to the current generation of children and adolescents [ 60 , 61 ].

The long-term psychological turmoil that young people and their parents have endured in the past few years outlasted the official end of the COVID-19 pandemic. As young people navigated difficult emotions, parents also suffered from substantial mental exhaustion. Therefore, family-centered treatment could be critically needed during this era of post-pandemic children’s mental health. This pilot study suggested that CHATogether is an acceptable, and feasible model of therapeutic intervention for children and adolescents presenting with mental health disorders by: (1) including the family as a focus of intervention within the bio-psycho-social framework of assessment and treatment; (2) providing a safe space for family members to process painful and frightening emotions during a psychiatric crisis, (3) promoting perspective taking, reflection, and more mature defenses within and between family members under stress, (4) improving effective family communication and problem solving, especially during times of crisis, and (5) restoring family cohesion after disruption, through enhanced mutual understanding, compassion, and hope within the family unit. Although more extensive studies are warranted, the results of this pilot study demonstrated the promising potential for the CHATogether program to serve as an innovative family therapeutic intervention during the post-pandemic era and beyond.

Availability of data and materials

The data would be available from the corresponding authors upon reasonable request.

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Acknowledgements

The authors would like to express special appreciation for the editing and critical review by Drs Janet Madigan, Michael Kaplan, and Linda Mayes from Yale Child Study Center, as well as Dr Rachel Ritvo from George Washington School of Medicine and Health Science. We appreciate Dr. Katie Klingensmith and Carol Cestaro, LCSW from Yale New Haven Hospital for their consultation in the development of this project. We are grateful for Willem Styles, LCSW, who provided clinical support in the program. Lastly, we express our gratitude to Dr Chiun Yu Hsu from State University of New York at Buffalo for his consultation in the psychometric measurements and critical review during the manuscript revision.

This work was supported by funds to EY, including the Riva Ariella Ritvo Endowment at the Yale School of Medicine; Yale New Haven Health System Innovation Awards; and NIH grants T32MH18268.

Author information

Caylan J. Bookman and Julio C. Nunes have contributed equally to this work.

Authors and Affiliations

Department of Psychiatry, Yale University, New Haven, CT, USA

Caylan J. Bookman, Julio C. Nunes, Ruby Lekwauwa & Eunice Y. Yuen

Cambridge Health Alliance, Harvard Medical School, Cambridge, MA, USA

Nealie T. Ngo

Yale New Haven Hospital, New Haven, CT, USA

Naomi Kunstler Twickler, Tammy S. Smith, Ruby Lekwauwa & Eunice Y. Yuen

Yale Child Study Center, New Haven, CT, USA

Eunice Y. Yuen

Yale Department of Psychiatry, 300 George Street, 06511, New Haven, CT, USA

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Contributions

CB and JN are co-first authors who contributed equally and were responsible for conceptualization, data curation, and writing the original draft and the major revision of the manuscript. NKT and NN contributed to the data collection, writing, and editing of the manuscript. TS and NKT contributed to skit video production and clinical implementation. RL was responsible for study conceptualization, reviewing, and editing manuscript. EY: designed the study, supervision, clinical implementation, and writing the manuscript. All authors read and approved the final manuscript upon to submission.

Corresponding author

Correspondence to Eunice Y. Yuen .

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Ethics approval and consent to participate.

The study obtained institutional review board approval from the Yale Human Investigations Committee (#2000034837). Families consented to study participation prior to the beginning of the survey. The study was entirely voluntary, and the families were welcomed to receive CHATogether treatment regardless of their participation in the study. In the pilot case, additional written consent was obtained from the family, and the case was de-identified with modifications to protect the patient’s and family’s privacy.

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Consent was obtained from the participants for publication.

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The authors declared that they have no competing interests.

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Bookman, C.J., Nunes, J.C., Ngo, N.T. et al. Novel CHATogether family-centered mental health care in the post-pandemic era: a pilot case and evaluation. Child Adolesc Psychiatry Ment Health 18 , 57 (2024). https://doi.org/10.1186/s13034-024-00750-y

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• Children and adolescent mental health
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Child and Adolescent Psychiatry and Mental Health

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MyHospitalVoice – a digital tool co-created with children and adolescents that captures patient-reported experience measures: a study protocol

• Jane Hybschmann 1 ,
• Jette Led Sørensen 1 , 2 ,
• Jakob Thestrup 1 ,
• Helle Pappot 3 ,
• Kirsten Arntz Boisen 4 ,
• Thomas Leth Frandsen 1 &
• Line Klingen Gjærde 1  

Research Involvement and Engagement volume  10 , Article number:  49 ( 2024 ) Cite this article

Metrics details

Children and adolescents have the right to participate in decisions concerning their health and express their views, also regarding hospital experiences. Patient-reported experience measures (PREMs) are valuable tools for systematically incorporating patient voices into healthcare systems. New developments have focused on PREMs for children and adolescents, though they are more commonly used in adults. A recent systematic review mapping their use for children and adolescents indicates a growing interest in this area. However, most PREMs are completed by proxy, in this case parents, so they do not necessarily reflect children’s experiences or align with their rights. Innovation is required to support and engage children and adolescents in responding to these types of questionnaires.

Collaborating with children and adolescents (4–17 years), the primary aim of this study is to develop and validate the tool MyHospitalVoice containing digital and developmentally appropriate PREMs. The secondary aim is to document and evaluate the approaches used to involve children and adolescents and to assess the impact of their involvement. Based on the European Organisation for Research and Treatment of Cancer framework, we will divide its development and validation into four phases. First, we will discuss PREM items with children and adolescents, who will select and prioritise what they perceive as most important. Second, we will create items targeting different age groups (4–7, 8–12, and 13–17 years) and design a responsive digital interface with child and youth friendly ways of responding to the questionnaires. Third, we will explore how children and adolescents perceive MyHospitalVoice using cognitive interviewing techniques and other age-appropriate methods. Last, we will pilot test MyHospitalVoice to explore patient experiences and response rates. In each phase, children and adolescents will play an active role. We will involve young adults as peer researchers in the project group to ensure that their perspectives are part of the decision-making process.

This project will contribute to research on co-creating with children and adolescents and enhance our understanding of their patient experiences. A validated tool like MyHospitalVoice can help improve quality of care by translating the needs and preferences of children and adolescents into clinical practice.

Plain English summary

We will collaborate with children and adolescents (4–17 years) to develop a digital tool called MyHospitalVoice. We believe that we can improve the quality of children and adolescents’ healthcare encounters by using MyHospitalVoice to incorporate their needs and preferences into clinical practice. Children and adolescents have the right to be involved in decisions about their health, also when in hospital. Being in hospital can be tough for children and adolescents and adults may not always pay enough attention to what children and adolescents experience. Giving children and adolescents an easy way to share their needs and preferences may protect their rights and ensure that healthcare professionals consider them more. One way to let patients share their hospital experience is by using questionnaires called patient-reported experience measures (PREMs). While similar tools are used for adults, there is a growing recognition of the need for them specifically tailored to the perspectives of children and adolescents. This project will develop a digital tool called MyHospitalVoice, which consists of PREMs designed for and with children and adolescents. We will follow a four-phase process based on established guidelines. We will gather existing PREMs and let children and adolescents decide which questions are most important to them. Next, we will create questions that are suitable for different age groups (4–7, 8–12, and 13–17 years) and design a user-friendly digital interface with playful features to make the questionnaire more engaging. Finally, we will assess how children and adolescents perceive MyHospitalVoice and end by doing a pilot test.

Peer Review reports

Children and adolescents have a right to participate in matters regarding themselves and their health, just as they have a right to express their own views [ 1 , 2 ]. These rights also apply to children and adolescents in hospital. Moreover, healthcare systems have a responsibility to facilitate and support these rights. Hospitalisation places children, adolescents, and their families in a particularly vulnerable life situation, where there may be little awareness of the child’s rights or the capacity to prioritise them. Thus, providing them with a tool to make their voices heard represents a way to secure these rights and put them more in focus. Patient-reported experience measures (PREMs) are a valuable method for systematically incorporating the voices and participation of children and adolescents into the healthcare system [ 3 ]. PREMs are questionnaires that systematically measure the patient experience, providing patients with the opportunity to express their views on their encounter with the hospital and healthcare professionals [ 4 ].

PREMs, which make it possible for hospital administrators and healthcare professionals to gain valuable insights into what is important from the patient perspective, are useful in identifying areas of improvement and in translating patient needs and preferences into actual qualitive improvement projects to promote patient-centred care [ 5 ].

Although PREMs are still more commonly used in adult patient populations, the development, validation, and implementation of PREMs for children and adolescents have increased rapidly over the last few years [ 6 , 7 ]. In 2021, a systematic review on their use for children and adolescents in high-income countries included 39 different PREMs reported in 83 peer-reviewed articles [ 4 ]. The review showed that only six of the 39 PREMs had been developed explicitly for completion by children and adolescents, with the remainder completed by parents (as proxies) or not reported. Asking the parents about their child’s experience does not correspond to the rights of the child, with research showing that parental evaluation of their child’s experience may not accurately represent the views and experiences of the child [ 8 , 9 ].

Since the review’s publication, more action has been taken to represent the voice of children and adolescents. The overall goal of a European project initiated in 2021 entitled, V alue o f i ncluding the C hildren’s E xperience for improving their right S during hospitalization’ (VoiCES) is to develop and implement a joint PREM observatory across European children’s hospitals [ 10 ]. Involving several phases and qualitative and quantitative methods, researchers, clinicians, children, adolescents, and families from Finland, Italy, Latvia, and the Netherlands participated in developing and validating the VoiCES PREMs. Consensus has been reached on a final version of (age grouped) PREMs but implementation is in its early stages. No results have been published yet and the questionnaires are not publicly accessible.

The implementation process plays a particularly key role in the feasibility and applicability of PREMs, just as the mode of administration has a prominent role. The VoiCES PREMs will be administered electronically, even though the authors of the aforementioned systematic review found that paper and pencil are still most commonly used [ 4 ], for example Wray et al.’s Children and Young People’s PREM (CYP-PREM), which was developed and validated for and with children aged 8–11 and 12–15 years of age at Great Ormond Street Hospital in London [ 11 ]. The CYP-PREMs have been translated and culturally adapted to at least four other languages [ 12 , 13 ].

The response rate on these paper-and-pencil PREMs in the UK is around 24% [ 14 ], which is considered acceptable but there is still room to engage even more children and adolescents in actively participating in the evaluation of their hospital experiences. In a study assessing the implementation of PREMs for children in Canada, McCabe et al. found that researchers, PREM administrators, and healthcare professionals express concerns about paper-and-pencil PREMs because they perceive this mode of administration as a hindering factor in their implementation and utilisation [ 15 ]. The authors set out a list of recommendations for integrating PREMs into the paediatric health system. Along with endorsing electronic platforms as preferable, the authors also list short yet flexible measures with multiple forms to reflect various age groups as a priority. They also stress the importance of clinicians knowing that the measures are relevant, reliable, and valid for their intended use. In addition, engaging patients, families, and staff in planning their implementation might also ease the implementation [ 15 ].

To accommodate these recommendations and address some of the challenges and gaps in research on PREMs for children and adolescents, we will build on the existing literature, co-create, and validate MyHospitalVoice in collaboration with children and adolescents with hospital experiences. The MyHospitalVoice tool will contain developmentally appropriate questions and response options (questionnaires) for children aged 4 to 7 year, 8 to 12 years, and adolescents aged 13 to 17 years about their hospital experiences and also feature an interactive digital interface that adapts to the age of the user (when they respond to the questionnaires). We intend to engage children and adolescents with hospital experiences not only as informants but also as active collaborators in shaping the project and during methodological considerations when appropriate and meaningful. Previous research shows that children and adolescents can contribute considerably as informants, testers, and to some extent as partners [ 16 , 17 ]. In accordance with the National Institute for Health and Care Research’s definition of the involvement of children as “research being carried out ‘with’ or ‘by’ rather than ‘to’, ‘about’ or ‘for’ them’” [ 18 ], we also consider the engagement of children and adolescents as co-creation, which is defined as “to create jointly” or “to create (something) by working with one or more others” [ 19 ].

Together with children and adolescents, our primary aim is to develop and validate MyHospitalVoice, while our secondary aim is to document and evaluate the approaches used to involve children and adolescents and to assess the impact of their involvement on the process and MyHospitalVoice.

The development of MyHospitalVoice will involve creating a set of developmentally appropriate items (questions and response options in the questionnaires) and also an interactive digital interface that adapts to the age of the users (this interface is what the child/adolescent sees when filling out the MyHospitalVoice questionnaires).

Based on the European Organisation for Research and Treatment of Cancer’s (EORTC) framework for developing and validating questionnaire modules [ 20 ], we will build on existing PREMs for children and adolescents [ 10 , 11 , 12 , 13 ] and collaborate with children and adolescents to co-create, digitalise, and validate our MyHospitalVoice PREMs.

Project structure, participants, and recruitment

Involvement of children, adolescents, and young people is central to this project, and the involvement appears on two separate levels: project level and content level (illustrated in Additional file 1 ).

At the project level, we will involve three adolescents and/or young adults as peer researchers in the project group which means they are involved in planning and conducting of workshops, interpreting and dissemination of results from the workshops, and discuss next steps throughout the study and thus share decision-making power with the researchers. They will be recruited through an established network called the Youth Panel at Copenhagen University Hospital – Rigshospitalet, Denmark [ 21 ]. The Youth Panel, which comprises 15 adolescents and young adult patients 15–24 years of age, meets eight times a year to discuss new initiatives to make the hospital more youth friendly. The Youth Panel also engages in training staff and quality improvement projects, in addition to awarding an annual prize to a healthcare professional who puts in a special effort for adolescents and young people. Although the young adults are not part of paediatrics in Denmark (0 to 17 years), we have chosen to involve young adults at the project level both for practical reasons (Youth Panel is already established) and to recognise the potential work burden and complexities of this project. To acknowledge the work burden, the Youth Panel members will be asked to engage for shorter time periods (e.g. 3 months) and then reconsider and potentially switch place with someone else at the end of the period. Those who engage will be paid for the time they invest in the project based on a student assistant salary rate. They decide how much time they invest in the project, but as a starting point they will be invited to: (1) An introductory meeting (about co-conducting research and PREMs), (2) Planning of one workshop (two meetings), (3) Co-facilitate a workshop, and (4) Discuss findings and next steps.

At the content level, we involve children and adolescents from the paediatric population (4 to 17 years, thus not the youngest age group of 0 to 3 years) though workshops. The workshops will be age grouped (4 to 7 years, 8 to 12 years, and 13 to 17 years) and be about either the age-specific questionnaire or age-specific digital interface. For these workshops, we will invite children and adolescents from various hospital departments at Rigshospitalet as well as children and adolescents who are part of the MARYS’ user panel [ 22 ], which is being used in the planning, development, and conceptualisation of Rigshospitalet’s new children’s hospital called Mary Elizabeth’s Hospital (MARY). The user panel is used to recruit participants, e.g., for user tests, focus groups, and research purposes. When the panel was established, information about it and how to register was published on social media forums and in posters and flyers at departments for children and adolescents at Rigshospitalet. To date, the user panel contains 127 children and adolescents 0–17 years of age and their or their parent(s)’ contact information. To recruit participants for the MyHospitalVoice project, we will contact them by e-mail using Research Electronic Data Capture (REDCap) [ 23 ].

For the workshops, the participant inclusion criteria are 4–17 years of age, having experienced being in a hospital, and being able to speak and understand Danish. In addition, the parents must understand written Danish, English, or another Scandinavian language to be able to provide written consent for their child’s participation. We have not predefined any other criteria for patient characteristics, e.g. gender or ethnicity, thus the recruitment is based on convenience sampling and might not represent marginalised voices. Workshop participants will have their travel costs reimbursed and food and drinks will be provided at the workshops.

Approaches to document and assess involvement

Standards for patient and public involvement in research and models for participatory design will guide the involvement of children, adolescents, and young adults [ 24 , 25 , 26 , 27 ]. We will report the involvement according to the Guidance for Reporting Involvement of Patients and the Public Checklist (GRIPP2) [ 28 ] (can be found in Additional file 2 ).

Preston et al. [ 29 ], who tested the Patient Engagement Quality Guidance Tool [ 30 ] in cases that involved children and adolescents in research, found that it was helpful and informative in terms of systematising reflections on the practicalities and experieces of involving them in research and to identify gaps in practice. Based on their suggestion, we used the tool in the planning stage but in an adapted version that is available in Additional file 1 .

Inspired by Dawson et al. [ 31 ] we state here our (a priori) planned involvement activities and will then compare them with the actual involvement activities at the end of the project. Our comparisons will be made based on notes and minutes from meetings. For each activity, we will reflect on whether our expectations were met and how the involvement impacted and shaped the project (Fig. 1 ).

Planned activities that are related to the involvement of children, adolescents, and young people. Preston et al.’s [ 32 ] matrix guided the use of wording

If we find that the degree and frequency of involvement is not feasible and/or meaningful, we will reconsider our initial plans and seek alternative ways to involve children, adolescents, and young adults. We expect our a priori and explicitly documented plan will help guide our evaluation of involvement and aid in defining and describing the facilitators and/or barriers to involvement, regardless of whether our approach is successful or will require an alternative plan. In Additional file 1 , we have included a matrix adapted by Preston et at [ 32 ] to illustrate our planned degree of involvement throughout the research phases.

The adolescent/young adult peer researchers will be asked to fill out the Patient Engagement in Research Scale (PEIRS-22) to measure the engagement at ‘project level’. The scale has been developed to measure meaningful patient engagement [ 33 ] and was recently translated and culturally adapted to Danish [ 34 ].

Phases of the project

Based on the EORTC framework, the development and validation process comprises four phases (Fig.  2 ) [ 20 ].

In phase 1 , the first author (JH) will extract data from existing PREMs for children and adolescents, translate the items into Danish, and categorise ones that relate to the same dimension. Without sharing these dimensions with the adolescent/young adult peer researchers, we will ask them to indicate which dimensions they perceive as important and to suggest new items. After this, researchers and peer researchers will discuss and compare the categories and dimensions based on existing PREMs and the ones the peer researchers provide. We will clarify the translations, rephrase, and choose between redundant items, if necessary. Based on the identified categories and dimensions, the researchers and peer researchers will plan co-creative workshops to be held in phase 2.

In phase 2 , we will conduct three age grouped workshops to co-create the questionnaire content, using participatory design methods to guide them [ 24 , 35 , 36 ]. The format and content will depend on the age group: 4 to 7 years, 8 to 12 years, and 13 to 17 years with eight to 16 participants at each workshop. For children and adolescents aged 8 to 17 years, parents are allowed to participate, if their child wants them to. For children 4 to 7 years, parents will participate but be encouraged to let their child be in control.

We will start with running workshops for the oldest age group and then progress to the younger ones building on knowledge gained in workshops for older children/adolescents.

JH will be responsible for organising the workshops and act as the primary facilitator, collaborating with the peer researchers. At the workshops and in developmentally appropriate, playful, and creative ways, the participants will be invited to explore hospital experiences and discuss, select, and prioritise which dimensions they perceive as most important in addition to adding new ones. To provide an example, the workshop for adolescents aged 13 to 17 years will consist of: welcome, ice-breaker activities, process exercises about hospital encounters and experiences, and evaluation and sum-up. A table of agenda and draft activities are provided in Additional file 1. The specific activities and exercises have not been decided yet, as they are to be designed in collaboration with young adult peer researchers, but they will be based on the Danish “Handbook for Child Involvement” ( Håndbog for børneinddragelse ) and Participation Works’ “The Toolkit” [ 26 , 27 ]. During the activities paper, cardboard, scissors, sticky tape, and stickers will be available and participants will be encouraged to draw, write, discuss, and reflect.

Development and validation of MyHospitalVoice. PREMs: patient-reported experience measures

Depending on the age group, we will discuss general considerations regarding questionnaire development, for instance introducing texts and type of response options (e.g. yes/no and Likert scales).

During the workshops researchers will take notes and each activity/exercise and its process and outcome will be reflected upon. After the workshops, the resulting materials will be collected and stored according to Danish regulations on data management. Based on workshop exercises, summing up, and the materials produced, JH will make a first draft of the dimensions, preliminary items, and results to present them to the researchers and peer researchers at a work meeting. JH will facilitate the meeting to ensure that the perspectives of both groups are included in the interpretation of data. We will also compare our items to original items from existing PREMs, and related questions will undergo forward-backward translations [ 37 ] to ensure comparability and research collaboration with other countries. The process will be iterative but will result in the first set of questionnaires for MyHospitalVoice.

We will then initiate an iterative creation of the digital interface for MyHospitalVoice (Fig.  3 ). Again, we will conduct at least three age grouped workshops: 4 to 7 years, 8 to 12 years, and 13 to 17 years with eight to 16 participants at each workshop, starting with the oldest age group. At these workshops, parents are welcome too, but with the child’s view and preferences being the central point.

Development of the digital interface for MyHospitalVoice

The children and adolescent for these workshops will be recruited from the same population as the first round of workshops (user panel and paediatric departments), but it is not a requirement to have participated in the first-round workshops about the questionnaire content.

The second-round workshops will engage the children and adolescents in the co-creation of the design of the digital interface. Their ideas will help to incorporate playfulness, storytelling, and perhaps gamification in the development of age-appropriate ways of responding to a questionnaire. Researchers have found that children and adolescents find it easier and more fun to answer questionnaires in an animated application than in a paper questionnaire or orally [ 38 ]. Thus, the digital interface for MyHospitalVoice will be age appropriate and incorporate playful aspects. The digital interface will undergo multiple testing and the same or new children/adolescents might be invited to several test sessions.

The questionnaire will be stored in REDCap, and the digital interface will be developed as a responsive website with an application programming interface that pushes data to REDCap when the questionnaires are filled out. Once the digital interface has been developed, we will establish this connection, resulting a beta version of MyHospitalVoice.

In phase 3 , we will conduct two types of pre-testing. First, the questionnaires will be administered to children and adolescents to identify and solve potential problems in phrasing and/or the sequencing of questions and to identify any missing or redundant items. In the second pre-test, we will conduct cognitive interviews with participants from the target population, children and adolescents with hospital experience, to investigate their understanding of the items in more detail. We will explore how they perceive the items (introductory text, questions, and response options), and the word choice. Cognitive interviewing methods will use the think-aloud method, where subjects are explicitly instructed to think aloud while answering the questionnaire [ 20 ]. Studies show that children as young as eight years of age can engage in this process and give meaningful feedback on their understanding of items [ 39 ]. After completing the two pre-tests, MyHospitalVoice will undergo refinement and, depending on the extent of the changes required, the pre-testing will be repeated.

In the last phase, phase 4 , we will pilot test MyHospitalVoice with approximately 200 children and adolescents from in- and outpatient departments at Copenhagen University Hospital – Rigshospitalet. They will also receive a short age-appropriate debriefing questionnaire. There are no formal requirements on sample size in developing and testing a questionnaire, but others have included 10 patients per item, though more with a heterogeneous target population [ 40 ]. In the later stages of the project, hospital department leaders will be consulted to help determine which patient populations will take part in pilot testing MyHospitalVoice.

We will evaluate the pilot test(s) by calculating response rates and exploring the factors that either hindered or facilitated implementation. Based on the evaluation, we may incorporate minor modifications. We will explore the psychometric properties of MyHospitalVoice using exploratory factor analysis, confirmatory factor analysis, Cronbach’s alpha, and differential item functioning analysis. We will also perform an exploratory analysis of correlations between experience factors and patient characteristics, e.g. age, disease severity, and prior hospitalisation, in addition to determining the required sample sizes to find associations between experience factors and, e.g. readmission.

Implementation of MyHospitalVoice

After conducting and evaluating our pilot study, we will implement MyHospitalVoice at Copenhagen University Hospital – Rigshospitalet in paediatric departments, adult departments, and outpatient clinics that admit children and adolescents. The implementation process will start in early phases of the project, so that the MyHospitalVoice tool is designed to fit into existing structures (e.g. the electronic health record system) and clinical practices. To do this, we will have ad hoc involvement of relevant stakeholders (e.g. clinicians, leaders, digitalisation and implementation managers). Implementation will adhere to existing management structures and be coordinated with other relevant bodies.

The Implementation Research Logic Model (IRLM), which will guide the implementation (Fig.  4 ), is a useful tool for planning, executing, and reporting the implementation of research projects [ 41 ]. IRLM incorporates aspects from other well-known implementation frameworks, including the Consolidated Framework for Implementation Research (CFIR) [ 42 ]. Factors from CFIR will be included in the first step in the IRLM to help identify the determinants of implementation that can act as either facilitators or barriers to successful implementation. The determinant domains, which include innovation, inner setting, outer settings, individuals, and process, will be identified partly through our pilot study and partly through discussions with stakeholders and staff. Based on the determinants, we will identify and select relevant implementation strategies to facilitate and ease implementation. The mechanisms that relate to how the implementation strategies affect the determinants and their implications for outcomes will be discussed and hypothesised in the research group and with relevant collaborators at Copenhagen University Hospital – Rigshospitalet.

Smith et al.’s implementation research logic model [ 41 ]

Collecting information on the hospital experiences of children and adolescents can help facilitate translate their needs and preferences into clinical practice and represent a possible way of operationalising patient-centred care. Thus, validated PREMs for children and adolescents can serve as a powerful tool when seeking to improve the quality of care provided to children and adolescents. In contrast to most PREMs for children and adolescents, MyHospitalVoice will provide an interactive digital interface to the questionnaire. A high response rate to the digital questionnaire that we develop will indicate that it is successful and likely increase the impact of MyHospitalVoice. Broad implementation will make rapid, real-time data analysis possible for the benefit of patients, healthcare professionals, and hospital administrators. Moreover, electronic storage of the questionnaire and responses will reduce the work burden for staff and administrators and promote the seamless spread of MyHospitalVoice.

The processes of co-creation during the development of MyHospitalVoice will generate valuable insights into conducting research that is done ‘with’ rather than ‘on’ children and adolescents. We hope to inspire and foster collaboration with other researchers in this area by sharing our methods, knowledge, and experiences of co-creating a digital evaluation tool with children and adolescents.

The results of co-creation will always depend on the people who participate, which is why being aware of and describing the background and prior experiences of researchers, peer researchers, and other participants is essential. Moreover, applying recognised frameworks and guidelines will strengthen our project and help increase the transparency and utilisation of our research.

Data availability

No datasets were generated or analysed during the current study.

Abbreviations

Consolidated Framework for Implementation Research

Young People’s Patient-Reported Experience Measures

European Organisation for Research and Treatment of Cancer

Guidance for Reporting Involvement of Patients and the Public Checklist 2

Implementation Research Logic Model

Patient Engagement in Research Scale

Patient-reported experience measures

Research Electronic Data Capture

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Acknowledgements

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Funding for this study was received from TrygFonden (grant no.153464) and Helsefonden (grant no. 21-A-0071).

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Mary Elizabeth’s Hospital and Juliane Marie Centre, Copenhagen University Hospital – Rigshospitalet, Blegdamsvej 9, Copenhagen, 2100, Denmark

Jane Hybschmann, Jette Led Sørensen, Jakob Thestrup, Thomas Leth Frandsen & Line Klingen Gjærde

Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3B, Copenhagen, 2200, Denmark

Jette Led Sørensen

Department of Oncology, Copenhagen University Hospital – Rigshospitalet, Blegdamsvej 9, Copenhagen, 2100, Denmark

Helle Pappot

Department of Paediatrics and Adolescent Medicine, Center of Adolescent Medicine, Copenhagen University Hospital – Rigshospitalet, Blegdamsvej 9, Copenhagen, 2100, Denmark

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JH, JLS, and LKG contributed to the conception and design of this study. JH wrote the initial draft manuscript and prepared the figures and tables. JLS, LKG, TLF, HP, JT, and KB revised the manuscript critically for important intellectual content. All authors approved the final version of the manuscript and agreed to be accountable for all aspects of it.

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This project adheres to the Danish Code of Conduct for Research Integrity and the Declaration of Helsinki. We will provide children, adolescents, and their parents with age-appropriate information about the study and inform of their right to withdraw from the study at any time. The information will include details on the scope and aims of the project, and we will ask children < 15 years for their assent to participate, while adolescents and young adults ≥ 15 year (and potentially parents) will be asked to provide written consent. In accordance with the General Data Protection Regulation, the project is registered with the Capital Region of Denmark’s Knowledge Centre for Data Review ( Videnscenter for dataanmeldelse ) (file no.: P-2022-458). The institutional review board of the Danish Research Ethics Committee (file no.: VEK22028868) evaluated this study even though ethics approval is not required.

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Hybschmann, J., Sørensen, J.L., Thestrup, J. et al. MyHospitalVoice – a digital tool co-created with children and adolescents that captures patient-reported experience measures: a study protocol. Res Involv Engagem 10 , 49 (2024). https://doi.org/10.1186/s40900-024-00582-2

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Received : 26 January 2024

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DOI : https://doi.org/10.1186/s40900-024-00582-2

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• Patient-reported experience measure
• Child participation
• Adolescent participation
• Research involvement
• Patient and public involvement
• Co-creation
• Hospital experience
• Quality of healthcare

Research Involvement and Engagement

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• About Adverse Childhood Experiences
• Risk and Protective Factors
• Program: Essentials for Childhood: Preventing Adverse Childhood Experiences through Data to Action
• Adverse childhood experiences can have long-term impacts on health, opportunity and well-being.
• Adverse childhood experiences are common and some groups experience them more than others.

What are adverse childhood experiences?

Adverse childhood experiences, or ACEs, are potentially traumatic events that occur in childhood (0-17 years). Examples include: 1

• Experiencing violence, abuse, or neglect.
• Witnessing violence in the home or community.
• Having a family member attempt or die by suicide.

Also included are aspects of the child’s environment that can undermine their sense of safety, stability, and bonding. Examples can include growing up in a household with: 1

• Substance use problems.
• Mental health problems.
• Instability due to parental separation.
• Instability due to household members being in jail or prison.

The examples above are not a complete list of adverse experiences. Many other traumatic experiences could impact health and well-being. This can include not having enough food to eat, experiencing homelessness or unstable housing, or experiencing discrimination. 2 3 4 5 6

Quick facts and stats

ACEs are common. About 64% of adults in the United States reported they had experienced at least one type of ACE before age 18. Nearly one in six (17.3%) adults reported they had experienced four or more types of ACEs. 7

Preventing ACEs could potentially reduce many health conditions. Estimates show up to 1.9 million heart disease cases and 21 million depression cases potentially could have been avoided by preventing ACEs. 1

Some people are at greater risk of experiencing one or more ACEs than others. While all children are at risk of ACEs, numerous studies show inequities in such experiences. These inequalities are linked to the historical, social, and economic environments in which some families live. 5 6 ACEs were highest among females, non-Hispanic American Indian or Alaska Native adults, and adults who are unemployed or unable to work. 7

ACEs are costly. ACEs-related health consequences cost an estimated economic burden of $748 billion annually in Bermuda, Canada, and the United States. 8

ACEs can have lasting effects on health and well-being in childhood and life opportunities well into adulthood. 9 Life opportunities include things like education and job potential. These experiences can increase the risks of injury, sexually transmitted infections, and involvement in sex trafficking. They can also increase risks for maternal and child health problems including teen pregnancy, pregnancy complications, and fetal death. Also included are a range of chronic diseases and leading causes of death, such as cancer, diabetes, heart disease, and suicide. 1 10 11 12 13 14 15 16 17

ACEs and associated social determinants of health, such as living in under-resourced or racially segregated neighborhoods, can cause toxic stress. Toxic stress, or extended or prolonged stress, from ACEs can negatively affect children’s brain development, immune systems, and stress-response systems. These changes can affect children’s attention, decision-making, and learning. 18

Children growing up with toxic stress may have difficulty forming healthy and stable relationships. They may also have unstable work histories as adults and struggle with finances, jobs, and depression throughout life. 18 These effects can also be passed on to their own children. 19 20 21 Some children may face further exposure to toxic stress from historical and ongoing traumas. These historical and ongoing traumas refer to experiences of racial discrimination or the impacts of poverty resulting from limited educational and economic opportunities. 1 6

Adverse childhood experiences can be prevented. Certain factors may increase or decrease the risk of experiencing adverse childhood experiences.

Preventing adverse childhood experiences requires understanding and addressing the factors that put people at risk for or protect them from violence.

Creating safe, stable, nurturing relationships and environments for all children can prevent ACEs and help all children reach their full potential. We all have a role to play.

• Merrick MT, Ford DC, Ports KA, et al. Vital Signs: Estimated Proportion of Adult Health Problems Attributable to Adverse Childhood Experiences and Implications for Prevention — 25 States, 2015–2017. MMWR Morb Mortal Wkly Rep 2019;68:999-1005. DOI: http://dx.doi.org/10.15585/mmwr.mm6844e1 .
• Cain KS, Meyer SC, Cummer E, Patel KK, Casacchia NJ, Montez K, Palakshappa D, Brown CL. Association of Food Insecurity with Mental Health Outcomes in Parents and Children. Science Direct. 2022; 22:7; 1105-1114. DOI: https://doi.org/10.1016/j.acap.2022.04.010 .
• Smith-Grant J, Kilmer G, Brener N, Robin L, Underwood M. Risk Behaviors and Experiences Among Youth Experiencing Homelessness—Youth Risk Behavior Survey, 23 U.S. States and 11 Local School Districts. Journal of Community Health. 2022; 47: 324-333.
• Experiencing discrimination: Early Childhood Adversity, Toxic Stress, and the Impacts of Racism on the Foundations of Health | Annual Review of Public Health https://doi.org/10.1146/annurev-publhealth-090419-101940 .
• Sedlak A, Mettenburg J, Basena M, et al. Fourth national incidence study of child abuse and neglect (NIS-4): Report to Congress. Executive Summary. Washington, DC: U.S. Department of Health an Human Services, Administration for Children and Families.; 2010.
• Font S, Maguire-Jack K. Pathways from childhood abuse and other adversities to adult health risks: The role of adult socioeconomic conditions. Child Abuse Negl. 2016;51:390-399.
• Swedo EA, Aslam MV, Dahlberg LL, et al. Prevalence of Adverse Childhood Experiences Among U.S. Adults — Behavioral Risk Factor Surveillance System, 2011–2020. MMWR Morb Mortal Wkly Rep 2023;72:707–715. DOI: http://dx.doi.org/10.15585/mmwr.mm7226a2 .
• Bellis, MA, et al. Life Course Health Consequences and Associated Annual Costs of Adverse Childhood Experiences Across Europe and North America: A Systematic Review and Meta-Analysis. Lancet Public Health 2019.
• Adverse Childhood Experiences During the COVID-19 Pandemic and Associations with Poor Mental Health and Suicidal Behaviors Among High School Students — Adolescent Behaviors and Experiences Survey, United States, January–June 2021 | MMWR
• Hillis SD, Anda RF, Dube SR, Felitti VJ, Marchbanks PA, Marks JS. The association between adverse childhood experiences and adolescent pregnancy, long-term psychosocial consequences, and fetal death. Pediatrics. 2004 Feb;113(2):320-7.
• Miller ES, Fleming O, Ekpe EE, Grobman WA, Heard-Garris N. Association Between Adverse Childhood Experiences and Adverse Pregnancy Outcomes. Obstetrics & Gynecology . 2021;138(5):770-776. https://doi.org/10.1097/AOG.0000000000004570 .
• Sulaiman S, Premji SS, Tavangar F, et al. Total Adverse Childhood Experiences and Preterm Birth: A Systematic Review. Matern Child Health J . 2021;25(10):1581-1594. https://doi.org/10.1007/s10995-021-03176-6 .
• Ciciolla L, Shreffler KM, Tiemeyer S. Maternal Childhood Adversity as a Risk for Perinatal Complications and NICU Hospitalization. Journal of Pediatric Psychology . 2021;46(7):801-813. https://doi.org/10.1093/jpepsy/jsab027 .
• Mersky JP, Lee CP. Adverse childhood experiences and poor birth outcomes in a diverse, low-income sample. BMC pregnancy and childbirth. 2019;19(1). https://doi.org/10.1186/s12884-019-2560-8 .
• Reid JA, Baglivio MT, Piquero AR, Greenwald MA, Epps N. No youth left behind to human trafficking: Exploring profiles of risk. American journal of orthopsychiatry. 2019;89(6):704.
• Diamond-Welch B, Kosloski AE. Adverse childhood experiences and propensity to participate in the commercialized sex market. Child Abuse & Neglect. 2020 Jun 1;104:104468.
• Shonkoff, J. P., Garner, A. S., Committee on Psychosocial Aspects of Child and Family Health, Committee on Early Childhood, Adoption, and Dependent Care, & Section on Developmental and Behavioral Pediatrics (2012). The lifelong effects of early childhood adversity and toxic stress. Pediatrics, 129(1), e232–e246. https://doi.org/10.1542/peds.2011-2663
• Narayan AJ, Kalstabakken AW, Labella MH, Nerenberg LS, Monn AR, Masten AS. Intergenerational continuity of adverse childhood experiences in homeless families: unpacking exposure to maltreatment versus family dysfunction. Am J Orthopsych. 2017;87(1):3. https://doi.org/10.1037/ort0000133 .
• Schofield TJ, Donnellan MB, Merrick MT, Ports KA, Klevens J, Leeb R. Intergenerational continuity in adverse childhood experiences and rural community environments. Am J Public Health. 2018;108(9):1148-1152. https://doi.org/10.2105/AJPH.2018.304598 .
• Schofield TJ, Lee RD, Merrick MT. Safe, stable, nurturing relationships as a moderator of intergenerational continuity of child maltreatment: a meta-analysis. J Adolesc Health. 2013;53(4 Suppl):S32-38. https://doi.org/10.1016/j.jadohealth.2013.05.004 .

Adverse Childhood Experiences (ACEs)

ACEs can have a tremendous impact on lifelong health and opportunity. CDC works to understand ACEs and prevent them.