2017 Children’s Mental Health Report

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Helping Adolescents Help Themselves

Adherence, therapeutic alliance, motivation for behavior change, and expectancies are common factors that cut across all pediatric psychiatric treatments. They can be harnessed to improve pharmacotherapy effects. They may even have independent treatment effects of their own. – Alessandro De Nadai et al

Personality traits and challenges that cut across disorders are called “common factors” in adolescent mental health. These include the ability to stick to treatment (adherence), the quality of the supportive therapeutic alliance of family and professionals around him or her, the willingness to address problematic thoughts or behaviors (motivation for change), and the expectation that treatment will be helpful. Research shows these factors can be leveraged to get young people into treatment, improve effectiveness of treatment, and even directly affect symptoms.

School-Based Approaches

We can have a wide-ranging impact on attitudes of entire school communities, and reduce impairing and even dangerous mental health symptoms.

  • The University of Alberta Empowering a Multimodal Pathway Towards Healthy Youth (EMPATHY) program ran in public schools from 2013 to 2015 and was offered to more than 6,000 youth in grades six through 12. Researchers found the percentage of the total school population who were actively suicidal decreased from 4.4 per cent to 2.8 per cent, in a follow-up study 15 months later. Rates of anxiety, depression and thoughts of self-harm also saw significant declines.¹
  • The Mental Health & High School Curriculum Guide (The Guide), a Canadian initiative, is a school-based mental health literacy program that educates adolescents about mental health and targets stigma. The curriculum includes information on specific disorders, and encourages a dialogue about seeking help and finding support. In a study of 534 students in 24 high schools in Canada, the 11th and 12th graders who were taught the curriculum improved significantly in positive attitudes toward mental illness and knowledge about mental health.²
  • An implementation of The Guide in Washington state shows it is effective in the United States as well. Some 400 students and 40 teachers trained in the program saw a 32% increase in student mental health knowledge and 68% improvement in mental health attitudes.³

Motivational Interviewing

Teenagers often resist treatment, dismissing it as something their parents want, rather than they want. Techniques designed to encourage teenagers to feel positive about treatment and to see treatment as relevant to their own goals has been shown to improve adherence to treatment and lead to better outcomes.

  • Motivational interviewing (MI) is an evidence-based intervention that explores a patient’s resistance to treatment with the aim of encouraging a more positive outlook. MI requires the patient to come up with positive things they can do, so they participate in determining their own treatment and play an active role in shaping it to their own needs.
  • MI leads to improved attendance and more treatment-seeking behavior compared with controls. MI participants attended significantly more therapy sessions and were 20% more likely to initiate treatment (96%) than the active control, befriending participants (80%)

Positive Expectations for Treatment

Adolescents who expect to see much or very much improvement from treatment improve significantly more than those with lower expectations.

  • In one study, higher pretreatment expectation of a medication’s effectiveness led to greater response. Participants who thought medication would be very effective had a 90.0% response rate, compared to only 33.3% of those who reported expecting medication to be only somewhat effective.

  • Expectations of treatment effectiveness have been shown to account for up to 31% of symptom improvement in a trial of cognitive behavioral therapy. It also predicts adherence to psychotherapy treatment (CBT homework).

[1] Silverstone, P. H., Bercov, M., Suen, V. Y. M., Allen, A., Cribben, I., Goodrick, J., … McCabe, C. (2017). Long-term Results from the Empowering a Multimodal Pathway Toward Healthy Youth Program, a Multimodal School-Based Approach. Frontiers in Psychiatry, 8, 81. http://doi.org/10.3389/fpsyt.2017.00081

[2] Milin, R., Kutcher, S., Lewis, S.P., Walker, S., Wei, Y., Ferrill, N., & Armstrong, M.A. (2016). Impact of a Mental Health Curriculum on Knowledge and Stigma Among High School Students: A Randomized Controlled Trial. Journal of the American Academy of Child and Adolescent Psychiatry. 55(5):383-391. doi: 10.1016/j.jaac.2016.02.018

[3] SAMHSA. (2017). NITT-TA Center Monthly Update. Retrieved from: http://www.k12.wa.us/SecondaryEducation/AWARE/pubdocs/2017-01-ProjectAwareSpotlight.pdf

[4] De Nadai, A.S., Karver, M.S., Murphy, T.K., Cavitt, M.A., Alvaro, J.L., Bengtson, M., Stock, S., Rakhshani, A.C., & Storch, E.A. (2017). Common Factors in Pediatric Psychiatry: A Review of Essential and Adjunctive Mechanisms of Treatment Outcome. Journal of Child and Adolescent Psychopharmacology. 27(1): 10-18. doi: 10.1089/cap.2015.0263

[5] Dean, S., Britt, E., Bell, E., Stanley, J., & Collings, S. (2016). Motivational interviewing to enhance adolescent mental health treatment engagement: A randomized clinical trial. Psychological Medicine, 46(9), 1961-1969. doi:10.1017/S0033291716000568

[6] Curry, J., Rohde, P., Simons, A., Silva, S., Vitiello, B., Kratochvil, C.,… (2006). Predictors and Moderators of Acute Outcome in the Treatment for Adolescents With Depression Study (TADS). Journal of the American Academy of Child & Adolescent Psychiatry, 45(12), 1427-1439. doi:10.1097/01.chi.0000240838.78984.e2

[7] Krell, H.V., Leuchter, A.F., Morgan, M., Cook, I.A., & Abrams, M. (2004). Subject expectations of treatment effectiveness and outcome of treatment with an experimental antidepressant. Journal of Clinical Psychiatry. 65(9): 1174-9.

[8] Lewin, A. B., Peris, T. S., Bergman, R. L., McCracken, J. T., & Piacentini, J. (2011). The Role of Treatment Expectancy in Youth Receiving Exposure-based CBT for OCD. Behaviour Research and Therapy, 49(9), 536–543. doi: 10.1016/j.brat.2011.06.001