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DRAFT
January, 2003
Risks Along the Road to Adulthood:
Challenges Faced by Youth with Serious Mental Health Problems
J. Heidi Gralinski-Bakkerab, Stuart T. Hauserab, Rebecca L. Billingsb,
and Joseph P. Allenc
a
Harvard Medical School
Judge Baker Children’s Center
b
c
University of Virginia
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Mental Health Problems in Context
Over the past twenty years the mental health of children and adolescents has been
a topic of growing national concern (US Public Health Service, 2000). To address this
concern, increasing clinical and research attention has focused on understanding the
childhood prevalence of psychopathology, the etiology and developmental course of
mental health problems, and the efficacy of various types of mental health treatment for
youth. Recent meta-analytic and epidemiological studies suggest that the prevalence
rates of psychiatric disorders among community youth range from 14% to 20%, with
most studies reporting overall rates somewhere between 17% and 20% (Schwab-Stone &
Briggs-Gowan, 1998). Within these percentages, 2% were found to have serious
disorders, 7% to 8% had moderately severe disorders, and the remainder had milder
forms of disorder which included diagnostic specific impairment nonetheless. Among
youths sampled from five public sectors of care--including mental health, child welfare,
juvenile justice, alcohol and drug, and primary health care sectors, Garland and her
colleagues (2001) reported relatively high prevalence estimates of disorder, with 54% of
these youth meeting criteria for at least one psychiatric disorder (Garland et al., 2001).
Due to these high prevalence estimates, there is a clear need to identify and
understand vulnerability and risk for disorders that emerge during childhood and
adolescence (Ingram & Price, 2001). Moreover, despite the availability of efficacious
and evidence-based treatments for some disorders, there has been growing recognition of
substantial continuity of mental health problems from adolescence to adulthood. Support
for continuity between symptomatology in adolescence and in later life has come from a
variety of sources, including analyses of vulnerability for psychopathology across the
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lifespan (Ingram & Price, 2001) and the Epidemiologic Catchment Area (ECA) studies
(Robins & Regier, 1991). In these studies, adult psychiatric disorders, on average, had a
reported age of onset for symptoms in adolescence. In addition, the disorders with an
earlier reported onset tended to follow a more chronic course and were associated with
the greatest disability during the adult years.
Youth with Mental Health Problems
In this chapter, we summarize what is known and what still needs to be studied
with regard to the period of transition from adolescence to young adulthood among youth
with serious mental health problems. Although this chapter focuses on an especially
vulnerable population--those with problems serious enough to warrant psychiatric
hospitalization, we also have included information about prevalence estimates of
psychiatric disorder among community and referred youth. Within this context of
community, referred, and inpatient populations, we describe findings regarding (a)
continuity of disorder from adolescence to young adulthood and (b) links between
adolescent-era disorders and a range of later outcomes. We focus primarily on
depression, anxiety and conduct disorders because these are the most common disorders
during adolescence (McGee et al., 1990). We also characterize adolescent disorders
within the context of broad dimensions of empirically-based syndromes or internalizing
and externalizing disorders (Achenbach & Edelbrock, 1983). In general, internalizing
disorders are marked by overcontrolled or troubled behavior, withdrawal from
interaction, anxiety, and depressed mood. In contrast, externalizing disorders are
typically characterized by undercontrolled or troublesome behavior, such as poorly
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controlled impulsive behavior, aggressive and antisocial behavior, as well as attention
problems and hyperactivity.
We chose to include information about community and referred youth, in part,
because few inpatient follow-up studies include comparison groups thereby leaving
unclear which results reflect the natural course of a disorder, developmental maturation,
effects of hospitalization, or potentially confounding factors that could account for the
results. This critical gap underscores the need to more fully understand the complexities
of mental health problems. For example, we need to know more about the consequences
for those with mental health problems and for their families and communities. At a more
fundamental level, Kazdin (1999, 2001) has drawn our attention to limitations in both (a)
our theories of dysfunction (which emphasize processes and mechanisms that build and
maintain maladaptive patterns of functioning) as well as (b) our theories of change
(which focus on factors and mechanisms that help to promote recovery). Indeed, the
editors of a special issue of the journal Development and Psychopathology suggest that
there is an urgent need for theoretically and methodologically rigorous science that can
explicate mechanisms responsible for the development, maintenance, and alteration of
mental health problems (Cicchetti & Hinshaw, 2002).
Within the field, there also are disagreements about what constitutes a serious
mental health problem, particularly at different points in the lifespan. For example,
epidemiological data indicate that one in ten children and adolescents in the United States
suffer from mental health problems serious enough to cause some level of impairment
(Shaffer et al., 1996). However, only one in five of these children receive specialty
mental health services--providing broad evidence that unmet need for services is high
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(Burns et al., 1995). Examination of the treatment literature suggests further that
definitions of a serious mental health problem and resources for mental health treatments
have been affected by two relatively recent changes in health care delivery systems:
managed health care and a continuum of care model for treating children’s mental health
needs.
Managed Health Care Systems
In the 1980s, health insurers began to monitor the way that physicians practiced
medicine, providing active oversight of clinical decision-making in the form of “managed
care” and “utilization management” (Tischler, 1990). Inpatient mental health care was an
early target for utilization review programs guided, in part, by the perception that there
was a substantial amount of inappropriate hospitalization in psychiatric facilities
(Hodgkin, 1992; Strumwasser et al., 1991). In general, concerns about services thought
to be too expensive or performed too frequently have led to a shift from inpatient
treatment to outpatient programs and other community-based care. In an effort to control
payment benefits, moreover, health insurers have challenged clinical treatment decisions
by imposing restrictions on the types of patients who may be admitted, the nature of
inpatient treatment, and the treatment length of stay (Glandon & Morrissey, 1986; Gray
& Field, 1989; Schlesinger, Dorwart, & Epstein, 1996).
Consistent with the philosophy of managed care, research on the role of youth
psychiatric facilities has shown a significant shift from relatively long-term treatment of
persistent mental health problems to short-term crisis management (Larzelere et al.,
2001). In addition to a declining length of stay for treatment, other changes have
included (a) a substantial change in the principal diagnoses of youth who are admitted
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(with major depressive disorders); and (b) a notable increase in use of medication during
hospitalization (Pottick, Barber, Hansell, & Coyne, 2001).
Whether these findings describe impacts of cost containment or patterns of
inpatient care is not clear. However, government surveys suggest that concerns about
treatment costs for the uninsured have led to socioeconomic disparities in access to
mental health care services, particularly for minority youth (US Public Health Service,
2000). In addition, data from follow-up studies of inpatient programs in Massachusetts
have shown that youth psychiatric readmission rates increased after the implementation
of managed care (Nicholson, Young, Simon, Bateman, & Fisher, 1996) with higher
readmission rates associated with reductions in length of stay (Wickizer, Lessler, &
Boyd-Wickizer, 1999).
Systems of Care
At the same time, a major change in the delivery of children’s mental health
services has been the “systems of care” model (Stroul & Friedman, 1996). This approach
to service delivery emphasizes a continuum of care that includes residential, intermediate,
and nonresidential services. While hospitalization is an important component of the
continuum, a key principle of the model is that services be provided in the least restrictive
environment. According to this model, the availability of intermediate levels of care
decreases hospital use by offering less restrictive alternative. Emphases on family
preservation also challenge the therapeutic appropriateness of hospitalization, especially
when other alternatives exist (MacDonald, 1994).
With this “systems of care” model in mind, a recent comparison of health delivery
systems showed higher rates of hospitalization among youth with traditional insurance
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coverage compared with those served in a continuum of care (Bickman, Foster, &
Lambert, 1996). The data also suggested that youth hospitalized under traditional
insurance coverage were less severely impaired than those served in the care continuum,
particularly with respect to internalizing symptom scores, self-harm, and history of
previous hospitalization. Despite these findings, empirical results to date are equivocal
on characteristics or predictors of hospitalization among youth. In general,
hospitalization criteria emphasize dangerousness to self or others (American Academy of
Child and Adolescent Psychiatry and American Psychiatric Association, 1997) and some
evidence suggests that clinicians consider both level of danger and diagnosis among
adolescents (Gutterman, 1998). Unfortunately, there is no standard regarding need for
hospitalization (Strauss, Chassin, & Lock, 1995) and we lack outcome data linking
hospital treatment to decreased problems or higher functioning relative to other
modalities of care.
Summary
Taken together, questions about appropriate use of hospitalization obscure our
knowledge about the extent to which hospitalized youth accurately represent those with
the greatest need. It also is not known how children in the most restrictive settings are
dissimilar to those in less restrictive settings, or how many youth with unmet mental
health needs may be ending up in the juvenile justice system where poor and minority
youth are disproportionately represented (US Public Health Service, 2000).
Primary Models of Psychopathology
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In studies conducted to date, sociohistorical trends in definitions and models of
disorder have affected the ways in which characteristics, course, and outcomes of mental
health problems are conceptualized. Some long-term follow-up studies have emphasized
models and definitions of disease or dysfunction. Within this medical model, people
either have a disease or not. For the most part, these studies have defined major types of
mental health problems as discrete groups of symptoms that indicate some type of
psychopathology within the individual and meet clinical diagnostic criteria for a disease
(Spitzer & Endicott, 1978). They also have examined relatively broad constructs or
indices of outcome over time. These include such markers as psychiatric morbidity,
criminality, reliance on disability benefits, service utilization, and links with death (e. g.,
Blotckey, 1984; Cohen, Cohen, & Brook, 1993; Kjelsberg, 1999; Thompsen, 1996).
Although specific findings will be summarized later, some researchers have suggested
that this interest in sickness corresponds to the societal construction that disease prevents
an individual from contributing to society (Sartorius, 2002).
A second set of studies adhere to a continuum conception in which some people
do not meet diagnostic criteria for a disorder but experience significant distress, life
disruptions, and difficulties functioning within the community. Within follow-up studies,
the focus has been on the degree to which people with disorders exhibit or report adaptive
functioning in a variety of life areas, including at work as well as with family and friends.
Particular attention has been paid to educational attainment as well as vocational,
interpersonal, and symptomatic behaviors likely to promote (or undermine) successful
functioning in the community (e. g., Gossett, Lewis, & Barnhart, 1983).
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A third nascent set of studies emphasizes integrative models of development and
psychopathology by stressing the importance of understanding mental health problems
within the context of competent or successful developmental outcomes (e. g., Cicchetti,
1984; Masten & Coatsworth, 1995; Steinberg, 2002). Within this framework, researchers
assume that the same processes affect typical and atypical development. For example,
children who successfully adapt to developmental demands (e. g., developing a sense of
self, establishing effective relationships with others) are likely to be oriented toward a
normative developmental trajectory whereas failure or difficulties in negotiating these
demands can place a child on a trajectory toward psychopathology (Cicchetti & Cohen,
1995b). Following from this perspective, models of psychopathology focus on the
importance of (a) identifying vulnerabilities within the child (that may be biological,
cognitive, affective, or social/behavioral); (b) describing contextual factors that may
interact with vulnerabilities to affect the extent to which tasks are successfully negotiated;
(c) isolating diverse developmental pathways over time; and (d) investigating
mechanisms that may account for differences in pathways and subsequent outcomes
(Cicchetti & Cohen, 1995a; Ingram & Price, 2001).
These three sets of studies reflect significant paradigmatic differences in ways in
which theorists and researchers think about the nature and course of psychopathology.
Although these differences limit direct comparisons of their findings, two general issues
regarding information about transitional youth with mental health problems are evident.
First, previous research has been limited by a number of methodological problems.
These include absence of control or comparison groups; small sample sizes often limited
to regional studies of primarily European American youth; and systematic biases in
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participants’ characteristics since ethical considerations prevent their random assignment
to a treatment or control condition. These methodological problems limit our confidence
in the validity and generalizability of results that have been found. Second, there is a
need for prospective, longitudinal, theoretically rigorous research focussed specifically
on the transition from adolescence to young adulthood among youth with serious mental
health problems. In many extant studies, data are retrospective or the reported successes
or failures associated with the transition to adulthood are limited by the study design and
the outcome(s) measured. As a result, there are gaps in our understanding of patterns or
profiles of multidimensional and multidirectional functioning (which allow for both
positive and negative outcomes in a variety of domains) across the transition as well as
prognostic factors and mechanisms likely to make a difference over time.
Despite these limitations, studies conducted to date collectively provide a
compelling picture of substantial personal costs for individuals who suffer from serious
mental health problems during the transition from adolescence to young adulthood.
There also are data regarding the developmental course of individuals who recover from
adolescent disorders.
Prospective Longitudinal Studies of Youth with Mental Health Problems
Recent findings from community-based longitudinal studies have suggested that
some adolescent disorders are relatively stable over time. For example, results from the
Dunehedin Multidisciplinary Health and Development Study showed considerable
continuity of diagnosed disorder with 63% of the adolescents who met explicit diagnostic
criteria age 15 also meeting criteria for a diagnosed disorder at age 18 (Feehan, McGee,
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& Williams, 1993; Feehan, McGee, Williams, & Nada-Raja, 1995). Findings from
studies examining patterns or syndromes of emotional and behavioral problems also
suggest that adolescent problems tend to persist into young adulthood (Achenbach,
Howell, McConaughy, & Stanger, 1995; Ferdinand & Verhulst, 1995; Ferdinand,
Verhulst, & Wiznitzer, 1995). Over an 8 year period, approximately 29% of Dutch youth
who could be regarded as having clinically significant problems during adolescence had
later significant problems. Among all youth with recurrent disorders, the data also
showed that there was a high degree of homotypic continuity between disorder types,
with externalizing disorders more likely to be associated with later externalizing disorder
and the same for internalizing disorders. Moreover, disorders with the poorest prognosis
in terms of increased risk for later disorder were aggressive conduct disorders and
multiple comorbid internalizing disorders (e. g., symptoms of depression in combination
with symptoms of anxiety).
Findings from follow-up studies of community and referred youth also suggest
that youth with disorders continue to struggle and have difficulty adjusting to adult life.
Farmer and her colleagues (2002) recently reviewed the evidence base for treatment of
childhood externalizing disorders and reported a range of later poor outcomes, including
school failure and drop out, substance use and abuse, unemployment, criminal activity,
early and inadequate parenting, and marital instability. Childhood internalizing disorders
have also been implicated in a number of poor outcomes, including subsequent bouts of
depression, suicidal behaviors, conduct problems, substance abuse, impaired
interpersonal relationships, and compromised performance at work (Birmaher et al.,
1996).
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Less is known from prospective longitudinal studies specifically focusing on the
period of transition from adolescence to young adulthood, a developmental period that
includes a number of normative challenges that may have important implications for
accomplishments in later life. National cross-sectional studies also indicate that the
young adult transition is the period of peak prevalence of psychopathology (Kessler et al.,
1994; Robins & Regier, 1991). These studies found that approximately one in four youth
reported signs and symptoms of a DSM disorder during the course of a year (e. g., Bird et
al., 1988; Lewinsohn et al., 1993, 1994, 1995; Wittchen et. 1998). Compared to people
aged 25-55, these youth were more likely to report a history of three or more disorders
within a 12-month period, placing them at high risk for recurrent pathology over their
lifetime (Kessler et al., 1994). In addition, Kessler and his colleagues (1994) argue that
those with a history of three or more disorders are among the 14% of the population who
“carry the major burden of psychiatric disorder” (p. 11).
Transitions and Emergent Adulthood
Despite the significance of these problems, there is a relative paucity of published
research focused specifically on the transitional phase to adulthood among youth with
mental health problems. Indeed, the transition among youth with problems serious
enough to warrant hospitalization is a subject on which relatively few systematic
prospective longitudinal studies have been published. This relative inattention is
surprising in light of the important developmental role of transitions in general (cf.
McAdams, 2000) and emergent adulthood in particular (cf. Arnett, 1998, 2000). Most
theorists and researchers agree that transitions are times that provide both opportunities
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for growth as well as exposure to risks. These times may impact a person’s life in ways
that affect their life trajectory or pattern of psychological functioning (Rutter, 1996).
Within the context of opportunity and risk, the transition to adulthood may be especially
important because it marks the beginning of a period of intensive preparation for entry
into adult roles (Perry, 1970/1999). It also involves a time when the focus is on leaving
home, developing autonomy, exploring various life possibilities--in love and work, and
making decisions about one’s own beliefs and values (Arnett, 1998, 2000; Erikson, 1950,
1968). With these fundamental life tasks in mind, those who negotiate the transition
without engaging in unhealthy and risky behavior are likely to be on their way to
productive and satisfying adult lives. In contrast, those who experience difficulty in the
transition may be at risk for long-term maladaptive functioning.
Among the goals that society expects youth to attain during this transition are the
ability to (a) live independently, (b) determine an initial career path, (c) find meaningful
employment or post-secondary education, (d) develop a social network of friends and
intimates, (e) prepare for adult family roles, (f) choose personally satisfying leisure
activities, and (g) participate as a citizen in a community (Arnett, 2000). For youth with
mental health problems, the challenge of successfully negotiating this transition may be
overwhelming because the skills that are central to successful transition often depend on
abilities that are already impaired. Poor adult functioning may, in effect, be a cumulative
outcome of failure over time. For example, severe psychiatric disorders typically disrupt
interactions thereby making it difficult for adolescents to learn more socially acceptable
ways of perceiving the world and responding to others (Elder & Caspi, 1988). These
disruptions may interfere with the acquisition of interpersonal skills and the processing of
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social information so that the risk of later social dysfunction and role disturbance is
heightened. In addition, serious mental health problems often impede the development of
competencies in crucial age-salient tasks (Masten & Coatsworth, 1995). As a result,
some adolescents do not have the competencies and resources needed to meet new
challenges. These may include deficits in important domains, such as academic
achievement, social competence, and self-regulatory and coping skills (Masten &
Coatsworth, 1995). They may also include dysfunctional peer and family relationships as
well as limited social and community supports (e. g., Feldman & Elliott, 1990).
Failure in these areas could then contribute to increasing distress and patterns of
problematic, dysregulated, disorganized, or dangerous behavior (e. g., social isolation,
moodiness, withdrawal, aggression,). When facing new challenges, adolescents may then
draw upon these established patterns of maladaptive behaviors leading to difficulty in
successfully negotiating the challenge or to failure (Cicchetti & Rogosch, 2002). In other
words, there may be transactions between adolescents’ mental health status and their
success or failure in important domains of adaptation, such that the two may become
increasingly intertwined over time (Shiner, Masten, & Tellegen, 2002). In turn, this
process may place adolescents with serious mental health problems at considerable
disadvantage as they face the transition to adulthood.
Links Between Psychiatric Disorders and the Transition to Young Adulthood
Recent findings present powerful evidence that many youth with mental health
problems continue to struggle during the transition to adult life. In a national community
sample, Kessler and his colleagues (1995, 1997) found significant links between
retrospectively reported information on age of onset of psychiatric disorders and the
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domains of education, parenting, and marriage. Compared to controls, people with a
history of early-onset psychiatric disorders were at high risk for reduced educational
attainment, teenage childbearing, and marital instability during adulthood (Kessler et al.,
1997; Kessler, Foster, Saunders, & Stang, 1995). In particular, youth with histories of
psychiatric disorder accounted for approximately 20% of the high school dropouts. Risk
proportions for teenage parenthood among youth with previous disorders ranged from
11.1% in a female subsample with premarital childbearing, 6.2% in a female subsample
with marital childbearing and 33.7% in a male subsample with premarital parenthood.
Moreover, 48% of those who had earlier psychiatric disorder were likely to divorce
compared to 36% of those who had no disorder before their first marriage. In each of
these domains, the highest risk of maladaptive outcomes occurred among males with
conduct disorders.
Using prospectively gathered information about adolescent psychiatric disorder in
a regional sample, Vander Stoep and her colleagues (2000) reported similar results .
Although the subsample with psychiatric disorder was relatively small (n = 33), the
prevalence rate of diagnosable disorders (18.2%) was similar to rates reported in recent
meta-analytic and epidemiogical studies (Schwab-Stone & Briggs-Gowan, 1998).
Comparing youth who had a psychiatric disorder with those who did not, this study
showed that adolescents with previous disorder had poorer outcomes across a range of
broad social and socioeconomic domains (Vander Stoep et al., 2000). These youth were
at high risk of failing to complete secondary school, being neither in school nor
employed, engaging in criminal activity (such as stealing, property damage, and
interpersonal aggression), and experiencing unplanned pregnancies. Proportions of youth
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experiencing each of these outcomes ranged from 24-39% among those with a psychiatric
disorder compared to 7-10% for those without disorder.
Within community-based prospective longitudinal studies, there also is growing
evidence to suggest that young people with a history of externalizing problems are at
particular risk for a range of social, psychological, and physical health problems. In their
pioneering work, Moffitt and her colleagues (2002) identified groups of 26-year-old
males who exhibited various degrees of antisocial behavior during childhood and
adolescence (Moffitt, Caspi, Harrington, & Milne, 2002). Of these 26-year-old males,
51% were unclassified because their antisocial behavior was approximately normative
from age 5 to 18 years; 8% were abstainers who had not engaged in antisocial behavior
from age 5 to 18 years; 10% were low level chronic offenders who met criteria for
extreme antisocial behavior in childhood but not adolescence and were at risk for a chain
of cumulative disadvantage in adulthood; 26% were adolescent onset offenders who
exhibited extreme delinquent involvement in adolescence and some adjustment problems
in young adulthood; and 8% were life course persistent offenders who exhibited stable,
pervasive, and extreme antisocial behavior beginning in childhood and continuing into
adulthood. For the low level chronic offenders, impairments included less education than
average, low-status occupations, many financial difficulties, and little hope for the future.
The adolescent onset offenders were at high risk of failing to pursue education beyond
high school, relying on crime for some of their income, and substance dependence
problems. Finally, life course persistent men had significant problems in multiple life
domains, including limited education, poor work histories, substance dependence
problems, serious criminal offenses, and a tendency to have many unplanned pregnancies
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but little involvement in parenting. Other research focusing only on girls found robust
links between adolescent conduct disorder and risky sexual behavior, unplanned
pregnancies, and young adult substance dependence. (Bardone et al., 1998). Moreover,
both males and females with a history of externalizing problems had partner relationships
characterized by personal ambivalence toward the relationship, poor conflict
management, physical violence, and uncertainty about the future (Woodward, Fergusson,
& Horwood, 2002).
Community studies have also found that depression occurring during adolescence
is linked with a range of impairments during early adulthood. Compared to their healthy
peers, people who met criteria for depression during adolescence were at risk for a range
of adverse psychiatric, social, psychological, and physical outcomes at age 21. These
included subsequent depression and anxiety, suicidal behaviors, internalizing behavior
problems, interpersonal problems, employment difficulties, a greater need for social
support, relatively low levels of self-esteem and life-satisfaction, alcohol abuse and
dependence, and physical health problems (Fergusson & Woodward, 2002; Giaconia,
Reinherz, Paradis, Carmola Huff, & Stashwick, 2001). In an effort to understand
whether adolescent depression played a direct or indirect role in these outcomes,
Fergusson and Woodward (2002) conducted additional multivariate analyses controlling
for a range of adverse social, familial, and personal factors that tend to be associated with
adolescent depression. These results suggested that many of the linkages arose because
adolescent depression occurred in the context of an individual’s personal and social
circumstances which, in turn, had linkages with the outcomes (Fergusson & Woodward,
2002). With the exception of a continuity from adolescent depression to later depression
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and anxiety, the associations between depression and other outcomes were explained by
confounding factors, such as parental educational achievement, parental change, exposure
to child abuse, IQ, and deviant peer involvement.
Summary
Limited space cannot do justice to the complexity of young adult outcomes
among transitioning community youth with mental health problems. As a result, we have
identified several important findings to address. These findings suggest a complex
matrix of difficulties faced by youth with mental health problems as they enter adulthood.
For example, minimal education will likely prevent some youth from attaining reasonable
and well-paying jobs and contribute to a downward socioeconomic spiral. Limited
economic resources in combination with early parenting may contribute to increased
family stress. In turn, family stress in combination with a physically violent relationship
may exacerbate marital instability, contribute to feelings of distress and uncertainty about
the future, and play a role in inappropriate parenting. Clearly, this compounding of
socioeconomic, psychological, and social outcomes underscore the many levels of
impairments that may be associated with mental health problems during the young adult
transition.
Characteristics of Youth with Serious Mental Health Problems
Although recent epidemiological data are limited, Burns (1991) examined crosssectional survey data collected by the National Institute of Mental Health (NIMH) and
found that 2% of the adolescent population aged 12-18 received mental health care in
1986. These estimates contrasted with the prevalence rates cited earlier suggest that 80%
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of youth with severe to moderately severe mental health problems have unmet service
needs. Among those who received care, 22% were admitted to inpatient psychiatric
facilities, with the rates of inpatient hospitalization highest among non-minority youth
(80%) with diagnoses of affective or behavior disorders. Using a model of health care
utilization that included illness factors, predisposing factors, and enabling factors, Pottick
and her colleagues (1995) reported 1986 national estimates indicating that diagnosis,
predisposing treatment history, and insurance coverage made a difference in uses of
inpatient versus outpatient care (Pottick, Hansell, Gutterman, & Raskin White, 1995). In
particular, adolescents with internalizing disorders were more likely to be hospitalized
than those with externalizing disorders; adolescents with histories of hospitalization or
other mental health care were more likely to be hospitalized than those without such
histories; and adolescents with private or public (Medicaid) insurance were more likely to
be hospitalized than those without insurance.
A recent review by Frensch and Cameron (2002) showed that studies of youth
served in different types of inpatient facilities found multiple problems in various
domains such as emotional and behavior problems, difficulties in school, and troubled
relationships. Although evidence regarding prevalence of particular diagnoses was
equivocal, the data suggested that diagnoses of conduct, attention deficit, depressive, and
anxiety disorders were common. Irrespective of diagnosis, common characteristics of
these youth included high levels of internalizing and externalizing behavior problems,
relatively poor adaptive functioning, chaotic behavior, poor impulse control, proneness to
harm themselves or others, destruction of physical property, use of physical threats, and
difficult relations with parents and peers. The evidence also showed that hospitalized
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youth came from families facing multiple psychosocial adversities. In particular, a
significant proportion of these families had histories of alcohol and drug abuse, family
violence, mental illness, and criminality (Quinton & Rutter, 1984a, 1984b). These
families were also found to have relatively high rates of marital instability, interparental
conflict, ineffective parenting styles, and unsupportive parent-child relationships. Parents
typically described themselves as experiencing high levels of stress, being unable to
control children in their home, having strained relationships with close relatives, and
generally lacking sources of support in the community (Jenson & Whittaker, 1989;
Quinton & Rutter, 1984b).
Presence of these clinical, personal, familial, and social characterstics may limit
treatment success among these adolescents. Moreover, the additive effects of these
characteristics, limited treatment success, and the special challenges of a life transition
may place some youth at extremely high risk of failing to make a successful transition
and damaging consequences.
Transition to Young Adulthood Among Youth With Serious Mental Health Problems
As described earlier, diverse models of psychopathology have emphasized a
variety of outcomes for youth who were hospitalized. However, few of these reports
provide specific evidence regarding the course and health of individuals at the
adolescence-to-adulthood transition. Studies that drew their samples from inpatient units
in which both children and adolescents were treated do not typically differentiate followup outcomes by age group. In studies focused solely on hospitalized adolescents, some
have relatively brief (e.g., 6 month to 2 year) follow-up periods, thereby yielding no
findings about the continuity of symptoms or level of functioning in young adulthood.
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Others have a relatively long period between hospital discharge and follow-up so that
little can be said specifically about the transition period.
Outcomes During the Transition to Young Adulthood
Among those studies which included a follow-up period that generally covers the
transition to young adulthood, the data provide information about diagnostic stability,
suicidal risk, and homelessness. Followed up two years after hospitalization, youth with
internalizing disorders revealed the highest percentage of persisting cases (59%) as well
as a significant number of new cases whereas youth with externalizing disorders had a
lower percentage of stable cases (39%) as well as fewer new cases over time (Mattanah,
Becker, Levy, Edell, & McGlashan, 1995). Data reporting relatively broad indicators of
success and failure over time have also shown that approximately 30% of a group of
adolescent “school refusers” appeared to be “disturbed” at a 10 year follow-up in contrast
with approximately 50% who were “much improved” (Berg & Jackson, 1985). This
estimate of relative failure is consistent with research examining posthospitalization risks
for suicide attempts. These data showed that approximately 25% of formerly
hospitalized adolescents attempted suicide within the first five years (Goldston et al.,
1999, 2001). Although those with a history of both suicidality and depression were at
greatest risk for clinically significant suicidality during follow-up, the likelihood of
suicidal behavior was not limited to those with previous suicidal behavior; it was
multiply determined. Irrespective of inpatient diagnoses, risk factors included a history
of suicide attempts, symptoms of depression and hopelessness, and trait anxiety with
associated feelings of agitation (Goldston et al, 1999).
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Estimates of homelessness among previously hospitalized adolescents suggest that
approximately 33% live on the streets (Embry, Vander Stoep, Evens, Ryan, & Pollack,
2000). Compared to former inpatients with a place of residence, youth at greatest risk for
homelessness had elevated rates of histories of drug or alcohol use, physical abuse, and
running away prior to treatment. Regardless of whether hospitalized adolescents carried
diagnoses of affective or conduct disorders, risks for later homelessness did not differ.
This heightened risk may occur, in part, because substance use can play a critical role in
alienating adolescents with mental health problems from their families. Substance use
can also impede occupational performance and limit wage-earning capacities. It may
also occur because alienation likely to be associated with histories of physical abuse
within the family may leave some youth with limited housing options or without stable
families to whom they can turn.
Adult Outcomes
Other follow-up studies of hospitalized adolescents tend to span periods that obscure
the special challenges of the transition to adulthood. Given what is known about the
continuity and homotypic nature of disorder over time, we have summarized key
information from these studies based on the uncomfortable assumption that functional
impairment or pathology that is present both in adolescence and later adulthood may have
traces present in the intervening, young adult period. While all of the following studies –
focused to one degree or another on constructs of functional impairment – are of such
lengthy follow-up duration that the transition period is obscured, they do offer important
findings about the continuity of disorder among previously hospitalized adolescents.
Risks Along the Road
23
Two related studies involve what is arguably the most “severe” of psychiatric
outcomes: death. In the first, Kjelsberg and her colleagues (1994) traced N=1,792
previously hospitalized adolescents after an average follow-up period of 15 years, finding
6-fold and 19-fold increases in suicide rates for males and females, respectively, relative
to community norms. In comparison to a matched group of living former patients, those
who had committed suicide were found to have had more difficulty with depressive
symptoms and with learning, poorer self-esteem, and a greater tendency to reject help
(Kjelsberg, Neegaard, & Dahl, 1994). In the second study, Kjelsberg and other
colleagues (1999) later traced a group of N=1,095 previously hospitalized adolescents
through a death registry, at a period ranging from 15 to 33 years post-hospitalization.
Being male, having a psychoactive substance use disorder, having had a short hospital
stay, and exhibiting poor impulse control were all found to be “strong and independent
predictors of death” (Kjelsberg, Sandvick, & Dahl, 1999). Male subjects with the
combination of psychoactive substance abuse disorder and poor impulse control were
found to have an “extremely high” mortality rate of approximately 40%.
Rather than focusing on symptomatology, suicide, or premature death, other studies
have examined aspects of poor functioning as defined by delinquency, criminality, and
disability. Continuing her series of Norwegian index register analyses, Kjelsberg with
Dahl (1999) found that among former adolescent psychiatric inpatients, 43.6% had
committed crimes during a 15 – 33 year follow-up period. Factors such as the nature of
the main diagnosis, and having experienced verbal abuse at home and discipline
problems at school, were strong and independent predictors of subsequent delinquency
for both males and females. Violation of ward rules during hospitalization was an
Risks Along the Road
24
additional strong predictor of delinquency among males, as was the presence of a
concurrent psychoactive substance use disorder among females.
In a related study, Kjelsberg (2002) more recently has reported that the presence
of psychoactive substance abuse disorder at index hospitalization and poor impulse
control were both correlated with a record of violent criminality for both genders.
Kjelsberg (1999a) also explored functional impairment by matching adolescents’
hospitalization records with Norway’s disability benefits register. These results showed
that overall low adjustment, low IQ, poor school performance, and self-harm behaviors
were predictors of later disability.
Each of these studies has focused on one aspect of maladaptive adult functioning and
sought adolescent-era correlates of the outcomes. In this process, each provides some
perspective on adolescent attributes and behaviors associated with subsequent difficulty.
Kjelsberg (1999b) took her studies one step further – this time by seeing what could be
learned from the histories of those former patients who, at follow-up, had thus far
avoided being recorded in all three of the death, disability, and crime registries. Among
males, psychiatric diagnosis, IQ >= 90, and the absence of both psychoactive substance
use and disciplinary problems in school were strong and independent predictors of a
“non-negative outcome” (Kjelsberg, 1999b). For females, diagnosis, lack of substance
use, and DSM-IV GAF >= 40 at admission were shown to be strong favorable predictors.
On the other hand, just 5.1% of males with substance use and school problems had a nonnegative outcome 15 years later. Females without substance use but with a GAF >= 40
experienced a non-negative outcome at a rate of over 75% 15 years hence.
Summary
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25
Despite a compelling story of damaging consequences, little attention has been
paid to patterns of failure or success. For the most part, this research has been conducted
within variable-centered approach rather than using a multivariate or person-oriented
design (Magnusson, 1988). As a result, there are questions about the people who make
the transition to adulthood. For example, do some young adults function effectively in
some domains but not in other domains? are there optimal patterns of effective
functioning or especially dismal patterns of failure? are there some young adults who
carry the burden of failure in multiple domains?
Paths Over Time
With its emphasis on diverse developmental pathways, the developmental
psychopathology model provides a framework to address such questions. This
framework has guided analyses of data from our longitudinal study, Paths Over Time and
Across Generations (Hauser et al., 1978; Hauser & Allen, 1988; Hauser, Allen, &
Crowell, 1992, 1994; Hauser, Allen, Crowell, & Gralinski-Bakker, 2002). This study
includes two cohorts: youth who were psychiatrically hospitalized as teenagers and a
comparison group of high school students Over the past twenty-five years, this research
has been guided by an interest in how adolescent psychosocial development and family
experience in both cohorts may contribute to important aspects of development and
functioning over the teenage and adult years. For example, a number of developmentally
salient indicators of psychological and social functioning were among those examined
over the teenage years (14 to 16). These included markers of the severity of symptoms
and diagnoses that characterized youth during their hospitalization; continuities and
Risks Along the Road
26
change in the framework of meaning that participants used (i. e., ego development,
Hauser, 1976,); ways that adolescents dealt with developmental challenges such as
establishing autonomy while maintaining a sense of relatedness in interactions with
parents (Allen et al., 1994; Collins, 1990; Grotevant & Cooper, 1985; Steinberg, 1990);
styles of dealing with everyday stressors and challenges; and ways that family members
facilitated or undermined youth positive growth and development.
With these rich descriptions of the teenage years--and the important role of these
indicators of (a) relative success at accomplishing adolescent-era developmental tasks
and (b) predictors of young adult outcomes, the study also explored links between
relative competence in accomplishing these tasks and a range of outcomes at age 25.
These outcomes have included young adult leaving home (O’Connor et al., 1996),
educational and occupational attainments (Bell et al., 1996; Best et al., 1997),
symptomatology (Gralinski et al., 1994), social adjustment (Allen et al., 1996), important
close and romantic relationships (Schultz et al, 19xx), and resilience (Hauser, 1997;
Hauser & Allen, in press).
We will summarize relevant aspects of this research in an attempt to extend our
understanding of (a) the transition to young adulthood among youth whose problems
were serious enough to warrant hospitalization; (b) vulnerability to pathological
outcomes; and (c) processes likely to make a difference. Include relevant research
We will also describe the importance of examining diverse developmental pathways
likely to be taken by youth who were hospitalized. Here we will focus on ways in which
Hauser and Allen (1997, in press) have identified resilient youth and characterized
narratives about their lives from adolescence to young adulthood.
Risks Along the Road
27
Future Directions
In this section, we will briefly summarize important gaps in our knowledge about
the transition to young adulthood among youth with serious mental health problems.
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