Introduction to the Special Section: Positive Developmental Strategies for Engaging Emerging Adults and Improving Outcomes
As compared to any other age cohort in the US population, young people in late adolescence and early adulthood have a higher rate of unmet need for mental health services. Not only are these young people (from about 16 to 25 years old, and referred to here as “emerging adults” 1) more likely to experience a serious mental health condition (SMHC), but they are also less likely to engage in services. Furthermore, when emerging adults do engage in services, they face multiple barriers to service continuity, particularly as they come up to “milestone” ages at 18, 21, and 24.
There is a growing body of research that documents the poor outcomes and adversities experienced by emerging adults with SMHCs; however, only recently has attention been turned to developing interventions that respond to their unique needs and preferences. A special issue of the Journal of Behavioral Health Services & Research (JBHS&R), published in 2015 2, highlighted new research focused on interventions and programs that have shown success in improving outcomes for emerging adults who experience serious mental health conditions.
Similar to the articles in the 2015 special issue of the JBHS&R, the articles that comprise this special section describe research that is grounded in what can be described as a “positive developmental” approach to working with emerging adults with SMHCs. The lead article in the 2015 special issue 3 described this positive developmental approach in terms of a set of core features that are commonly shared across interventions and programs that have empirical evidence of effectiveness in engaging and improving outcomes for emerging adults. Foremost among these features is a focus on self-determination and/or self-efficacy, typically realized through an individualized, person-centered planning process that “takes its direction from the young person’s perspectives, priorities, and preferences; incorporates and builds on the person’s strengths and interests; and fosters connections to community and natural supports” 3 (p. 133). Other shared features include having the provider work with the young person in a strengths-based manner and addressing multiple domains of functioning. The subsequent articles in the 2015 special issue of the JBHS&R described diverse strategies that are being used to develop and evaluate interventions that include features of the positive developmental approach and that are designed specifically to improve outcomes for emerging adults with SMHCs. The articles in this special section continue in a similar vein, focusing on how these shared features, particularly person-centered planning and other activities to enhance self-determination, are conceptualized and integrated into services for emerging adults.
For example, Walker and Flower 4 describe findings from a qualitative study based on interviews with practitioners who used positive developmental interventions for working with emerging adults, and who had been nominated as being exceptionally experienced and effective. The aim of the study was to understand more about the extent to which these providers ascribed to a common set of practice principles (e.g., promote self-efficacy/self-determination, work in a strengths-based mode), how they defined these principles, and how they translated these principles into specific types of activities and interactions with young people. The study did find a high degree of consensus around practice principles and their definitions; however, practitioners had difficulty describing specific elements of their interventions that reflected the principles. The authors argue that this implies the need for better theoretical understanding of how positive developmental interventions produce desired outcomes. In turn, this should help providers to “identify the active ingredients of their practice, and, presumably, to utilize these in a more intentional and impactful manner” 4.
The article by Munson et al. 5 describes a project that conceptualized, developed, refined, and tested the feasibility and acceptability of an engagement intervention designed with and for young adults with SMHCs. The Just Do You intervention aims to improve self-efficacy and empowerment among young adults, as well as to enhance engagement in mental health services among young adults through explicit acknowledgement that they are the “drivers” in their mental health care. Munson et al. conducted key-informant interviews with young adults diagnosed with a SMHC, recovery role models, and key stakeholders (clinic staff, administrators, and experts in the field) to evaluate the feasibility, acceptability, and implementation demands of the intervention. Findings suggest that young adults found the overall program to be engaging and helpful, and some of the young adults reported that the program had a positive impact on their attitudes toward and motivation to engage in services.
Brennan et al. 6 analyzed data from the National Longitudinal Child and Family Outcome Study, examining education outcomes for emerging adults ages 17 to 22 who received mental health services in systems of care. The study evaluated the relationship between the young peoples’ experiences in mental health services and their educational outcomes, including school functioning and performance, completion of degree, and enrollment in higher education. Regression analysis revealed that young peoples’ experience in services added to the significant prediction of satisfactory school performance, even controlling for sex and attendance. Additionally, participation in planning their own services significantly predicted enrollment in higher education for those who finished high school. Brennan et al. argue that these findings suggest that programs and practices based on positive youth development approaches can improve educational outcomes for emerging adults.
Stein et al. 7 present findings from a series of focus groups with emerging adults (aged 17–23), caregivers, staff, and supervisors. The focus groups were part of the evaluation of the federally funded Healthy Transitions Initiative (HTI) program in Maryland. Maryland HTI service providers utilized interventions informed by the Transition to Independence (TIP) model, which is based in a positive developmental framework. Providers also used other evidence-based practices, including supported employment. Participants in the focus groups provided their perspectives on services, program strengths, and areas for improvement. Findings affirmed the importance of community-based instruction and involvement, self-determination, social connectedness, and family involvement. Suggestions for program enhancement included a desire for more socialization opportunities, increased support for youth and caregivers in navigating systems and agencies, and greater informational and staff resources to address the complexities of multi-system involvement.
Cappelli et al. 8 describe findings from a study of the Youth Transition Project, which was an effort to promote continuity of mental health and addictions care as emerging adults transitioned from child and adolescent mental health services to adult mental health services in Ottawa, Ontario, Canada. Young people in the study participated in individualized transition care planning aimed at promoting coordination and continuity of care. This process was supported by a transition coordinator, who acted as a system navigator by preparing youth and families for transition, coordinating referrals, and ensuring the young people were seen in a timely manner and remained engaged in services. Evidence from the study indicated the program was successful in promoting continuity of care, with most of the young people continuing to be engaged in an appropriate level of mental health services.
The final article, by LaPorte, Haber, and Malloy 9, examines the composition of teams providing Wraparound, which is a process for developing and implementing an individualized, comprehensive plan of care for a young person with a SMHC. In addition to the young person and his/her family members or other caregivers, Wraparound teams typically include a blend of formal service providers (e.g., care coordinator, therapist) and “informal” supports (e.g., friend, mentor). Previous research has suggested that, as young people approach adulthood, they may become reluctant to engage with family and professionals in team-based planning such as that undertaken in Wraparound. The article reports on the relationship between team composition and youths’ self-determination and satisfaction with Wraparound. Findings from the study supported both the feasibility and the benefits to youth self-determination and satisfaction of involving caregivers, teachers, and human service professionals on teams.
Implications for Behavioral Health
Taken as a group, the studies included in this special section of the JBHS&R bolster existing findings regarding the potential benefits, both in terms of increased engagement and in terms of improved outcomes, of service strategies based in an understanding of positive development during emerging adulthood. In particular, the studies reinforce the importance of intervention activities or elements that promote connections to natural community settings, support significant relationships in a young person’s life, and enhance self-determination and/or empowerment. Of course, further research will be needed to explore how these positive development-oriented strategies should be structured and implemented so as to maximize benefit. Once this is better understood, further research will be required to establish the most effective ways of training and supporting providers (including the providers of peer interventions and other non-traditional strategies) so they acquire the needed competencies. Additionally, system-change research will be required to build knowledge about effective strategies for making services and supports more accessible, for reducing service fragmentation, and for facilitating widespread replication of effective programs, interventions, and models of services delivery and workforce development. It is encouraging that attention is increasingly turning to these topics, as is demonstrated by the contributions in this special section, as well as in the 2015 special issue of the JBHS&R.
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