young people accessing mental health services Alice Joan Cairns

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1 Exploring help-seeking, vocational role function and goal setting of young people accessing mental health services Alice Joan Cairns BOccThy, GCResMeth Submitted in fulfilment of the requirements for the degree of Doctor of Philosophy Institute of Health and Biomedical Innovation (IHBI) and School of Public Health and Social Work Faculty of Health Queensland University of Technology 2017

2 Abstract Adolescence and young adulthood is a time of considerable neurobiological, social and occupational change. The combination of these factors appears to increase vulnerability to mental illness, which can disrupt neurocognitive and functional development and potentially have serious consequences for individuals and their families. There is reasonable evidence that young people with a diagnosed mental illness are more likely to experience difficulties with role function and this is particularly true for young people who report greater severity of symptoms than their counterparts. Elevated distress, with or without a mental health diagnosis, is endemic in young people. However, the capacity of young people experiencing distress to successfully fulfil their desired and necessary life roles have not been fully explored. The overall theme of this doctoral programme of research is exploring the functional concerns of young people seeking help from youth primary health services. This was firstly explored through a qualitative study where year olds accessing a youth health organisation were interviewed. The interviews focussed on why they were seeking help and what areas in their life they were having difficulties with. Four prominent and interrelated themes emerged from these interviews including difficulties with: managing feelings and emotions; relationships; employment; and risk taking behaviour. A number of participants reported difficulties with role function (such as employment) as a result of some of their other issues such as anger or risk taking. A key theme from this data were the age related difference between participants who reported concerns with employment (over 18 years of age) and those reporting concerns with relationships (14-18 years of age). ii

3 The presenting issues of young people were further investigated using a cross-sectional sample of 283, year olds who were also seeking help from a youth health service. Initial clinical assessment information from the health service records for the 283 participants was analysed. This analysis identified that the most commonly reported presenting issue was psychological, although issues with relationships (social) and employment or education (vocational) were reported in 55% and 43% of the sample respectively. The presence of a mental health diagnosis did not predict any of the specific presenting problems, suggesting the likely co-existence of psychological and functional issues even in young people experiencing distress who may not have a diagnosed mental illness. With almost half of the participants presenting with issues relating to work or study, the focus on functional concerns was narrowed to explore vocational role function in the year olds to align with current research in this field and mandated school age laws. Analysis from 226 participant clinical charts identified that 53% of participants were either not working or studying, or participating in a part-time capacity. Not completing secondary education and drug use were predictive of not working or studying, however this association was not observed in those participating part-time. To overcome some of the limitations of the data collected through chart auditing, a prospective cross-sectional study investigated demographic, clinical and neurocognitive correlates of vocational role function in 107 young help-seeking adults. Impaired decision making, impulsivity and working memory strategy formation were all associated with either a lower level or quality of vocational participation. Once demographic and clinical variables were controlled for, working memory strategy formation was the only significant neurocognitive correlate of the level of vocational iii

4 engagement. Factors such as gender, family history of schizophrenia or bipolar disorder, socioeconomic background, whether the person completed secondary school, and cannabis use in the last 30 days were more consistent predictors of both employment and educational role performance. The final section of the thesis explored functional concerns through goal setting. Firstly, young people who participated in the qualitative interviews were also asked at the time of the interview if they could transform one of the areas they were concerned with into a goal for therapy using the Goal Attainment Scaling worksheet. All participants completed the worksheet, and the themes that arose from the subsequent discussion from this process focussed on the ownership over the physical location of goals and the use of the scale as a motivator for behaviour change. During the interviews, participants reported setting goals during their initial service intake assessment. These discussions raised questions about the use of goal setting during the initial service intake assessments. Exploring the frequency and quality of goal setting with youth help-seekers was the last study in this doctoral programme of research. Data collected from the 283 participant chart audits were used to explore the quality of goal setting in a youth mental health service and the potential relationship with service engagement. Of the 283 charts reviewed, 187 participants had set goals. Young people who did not set goals were more likely to disengage from the service after the intake assessment, possibly a reflection of commitment to ongoing therapy. A subanalysis of 166 goals from 74 clinical charts against SMART (specific, measurable, achievable, realistic/relevant and timed) criteria identified that 57% were specific but only 14% were specific and measurable. Setting any type of goal was predictive of a greater iv

5 number of sessions attended. Setting a measurable and specific goal did not improve the number of sessions attended compared with a goal that was not specific nor measurable. Taken together, results suggested concerns with role function co-existing with psychological issues, and that vocational role function is restricted in almost half of all people accessing youth mental health services. Most measures of cognitive capacity did not meaningfully differentiate work and study outcomes after potential confounders in young people over 18 years of age. However, the significant association between vocational participation and the capacity to plan and implement an effective strategy for task completion could be of benefit to clinicians and researchers. The effectiveness of interventions aimed at improving vocational participation may be enhanced by assessment and counselling of task strategy as well as targeting behavioural change such as alcohol and drug counselling and school-based support to improve secondary school completion. Young people found documenting functional concerns through formal goal setting an acceptable and valuable process. However, the audit of routine clinical practice indicated that goals set during service assessment were neither specific nor measurable, thus potentially reducing the usefulness of these goals to evaluate functional change designated by the young person as meaningful. This research adds to the body of evidence supporting the high rates of concern regarding role function that co-exist with psychological reasons for seeking help. Strengthening goalsetting practices already occurring in youth services by setting goals that are specific and measurable and adding a formal mechanism for goal evaluation could provide a costeffective method to simulate motivation for behaviour change and evaluate client-desired meaningful outcomes. v

6 Anthology of Publications Journal articles in order of presentation within this thesis 1. Cairns, A., Dark, F., Kavanagh, D. & McPhail, S. (2015). Exploring functional concerns in help-seeking youth: a qualitative study. Early Intervention in Psychiatry, 9(3), Cairns, A., Kavanagh, D., Dark, F. & McPhail. S. (2017) Service disengagement and presenting issues from young people seeking help: predictors and implications for practice. Under review with a peer-reviewed journal. 3. Cairns, A., Kavanagh, D., Dark, F. & McPhail. S. (2017). Comparing predictors of parttime and no vocational engagement in youth primary health services: A brief report. Early Intervention in Psychiatry, in press.. 4. Cairns, A., Kavanagh, D., Dark, F. & McPhail, S. (2017). Prediction of vocational participation and global role functioning in help-seeking young adults from neurocognitive, demographic and clinical variables. Under review with a peerreviewed journal. 5. Cairns, A., Dark, F., Kavanagh, D. & McPhail, S. (2015).Setting measureable goals with young people: qualitative feedback from the Goal Attainment Scale in youth mental health. British Journal of Occupational Therapy, 78(4), Cairns, A., Dark, F., Kavanagh, D. & McPhail, S. (2017). Focusing on function in youth mental health. Could goal setting help engagement? Under review with a peerreviewed journal. Conference presentations vi

7 1. Cairns A, McPhail S, Dark F, Kavanagh D (2012). Functional concerns of help seeking youth. Queensland Occupational Therapy Conference, Cairns, Australia. 2. Cairns A, McPhail S, Dark F, Kavanagh D (2012). Identifying, measuring and remediating cognitive and functional deficits in help seeking youth. PhD programme of research. Metro South Mental Health Research Forum, Brisbane, Australia. vii

8 Keywords CANTAB, cognition, cross-sectional analysis, early intervention, education, employment, functional concerns, goal-based outcomes, Goal Attainment Scaling, goal setting, helpseeking, psychological wellbeing, qualitative, role function, SMART goals, study, vocational participation, work, young person, youth mental health viii

9 List of Figures Figure 1.1 Structure of program of research... 6 Figure 3.1 Intra-extra dimensional set shift (CANTAB) Figure 3.2 Rapid Visual Processing (CANTAB) Figure 3.3 Spatial Working Memory (CANTAB) Figure 3.4 Paired Associate Learning (CANTAB) Figure 3.5 Information Sampling Task (CANTAB) Figure 5.1 Psychological distress (K10) scores (n=270) in categories of low or no (10-15), moderate (16-21) high (22-29) or very high (>30) psychological distress Figure 5.2 Number of presenting issues per participants (n=270) Figure 8.1 Goal Attainment Scale (participant 10, female, 14 years) Figure 9.1 Number of goals recorded per participant (n=74) ix

10 List of Tables Table 4.1 Participant demographics ordered by age Table 4.2 The emerging framework of four overarching themes, and categories within each theme Table 5.1 Participant characteristics of the sample n= Table 5.2 Summary of multiple logistic regressions examining potential correlates of presenting issues reported by young people (n=270) Table 5.3 Summary of the logistic regression model (LR X 2 (10) = 19.42, p=0.04) examining associations between disengagement and variables listed (n = 263) Table 5.4 Staff reported reasons for disengagement (n=283). Attended initial assessment session only (n= 55) Table 6.1 Participant characteristics, n= Table 6.2 Summary of the multinominal logistic regression (LR X 2 (12) = 97.8, p<0.001) n=223, examining associations between level of vocational engagement (compared to full time) and age, secondary school dropout, mental health (MH) diagnosis, K10 (Kessler distress scale) and history of drug use Table 7.1 CANTAB subtests Table 7.2 Vocational, demographic and clinical characteristics of the sample Table 7.3 Raw and z-scores for the individual neurocognitive tests Table 7.4 Results from univariate ordinal logistic regressions examining potential correlates of vocational functioning (n=107) Table 7.5 Results from multivariable hierarchical ordinal logistic regressions examining potential correlates of vocational functioning, n = x

11 Table 8.1 Participant demographics Table 8.2 Overall goal themes (related to person s role), categories and number of participants who identified with these categories Table 9.1 Type of goals reported by help-seeking young people. 166 goals analyzed Table 9.2 Results from univariate and multivariate negative binominal regressions examining potential correlates of number of sessions attended (dependent variable) n= Table 9.3 Results from univariate and multivariable logistic regression examining potential correlates of goal setting (dependent variable) xi

12 List of Abbreviations and Glossary SMART CANTAB K10/Kessler 10 GAS NEET OECD PLE CAPE CAPE-P Specific, measurable, acceptable/achievable, realistic and timed (goals) Cambridge Neuropsychological Testing Automated Battery Kessler Psychological Distress Scale, 10 questions Goal Attainment Scaling Not in Employment, Education or Training Organisation for Economic Co-operation and Development Psychotic-like experiences Community Assessment of Psychic Experiences Community Assessment of Psychic Experiences Positive symptom domain CAPE-P15 Community Assessment of Psychic Experiences Positive symptom domain, 15 question. GHQ F/T P/T GFR IED RVP SWM PAL IST General Health Questionnaire Full-time Part-time Global Functioning: Role scale Intra-extra Dimensional Set Shifting Rapid Visual Information Processing Spatial Working Memory Paired Associates Learning Information Sampling Task xii

13 AUSE106 Australian Socioeconomic Index 2006 OR CI SD IQR SOFAS IPA M F Odds Ratio Confidence Intervals Standard Deviation Interquartile Range Social and Occupational Functioning Assessment Scale Interpretative phenomenological analysis Male Female Young person, youth, adolescent: A young person is defined as those aged between 12 and 24 years of age by the Australian Institute of Health and Welfare [1]. Youth early intervention organisations mostly target this age range, as this is the developmental and social age of transition from childhood to adult. This thesis used young person interchangeably with adolescent and youth unless a more constricted age range is provided. Emerging adult, young adult: An emerging adult is considered between years of age. Although some researchers view emerging adulthood as a separate developmental period to being a young adult [2], these terms are used interchangeably in this thesis. Function, functional, functioning: Function or functional refers to an activity or action that is proper or natural for a person. A person's level of functioning can be described at the activity, task or role level. For the purpose of this thesis, function is mostly referring to the role level. For example, social functioning refers to a person's ability engage and develop age appropriate relationships with others. xiii

14 Help-seeking, help-seeker: The term 'help-seeker' is used to describe a cohort of young people who are attending health services. In this thesis all participants sought help from a youth-specific primary health service that specialise in mental health. Help-seeking is not a diagnostic term. headspace: headspace is the Australian National Youth Mental Health Foundation. It is funded by the Australian Commonwealth Government and their focus is the mental health and wellbeing of all young Australians. xiv

15 Statement of Original Authorship The work contained in this thesis has not been previously submitted to meet requirements for an award at this or any other higher education institution. To the best of my knowledge and belief, the thesis contains no material previously published or written by another person except where due reference is made. I do declare the above statement is true and correct QUT Verified Signature Alice Cairns 09/05/2017 xv

16 Acknowledgements Firstly I would like to thank my three supervisors, Steven McPhail, Frances Dark and David Kavanagh. I am incredibly grateful that they saw potential in me and agreed to support me on this journey. Without the time, guidance, advice, skill and support from all three supervisors this incredible learning opportunity would not have been realised. This program of research relied on the support of the headspace staff and clients at the two participating sites. Thanks needs to go to both centres as they were incredibly generous with their resources, time and support. I need to especially mention the young people who participated in this project. Their willingness to help me when they were experiencing difficulties and distress speaks volumes of their resilience and selflessness. Thank you to my family and friends. I cannot imagine a PhD being completed without a cheering squad, and so many were willing to let me debrief and provide advice and support when I felt overwhelmed. In particular Jo Hodgson, Ruth Lord and Andrea Cairns; three great women in my life who always made me feel that I had the skills and tenacity to see this through. Finally, thanks needs to go to my husband and our two little children; Nick for his unwavering support, endless encouragement and willingness to take on almost all domestic duties as I got to the pointy end of this degree, and to Harold and Eleanor who were born during this PhD process. I hope I have demonstrated what hard work, determination and positivity can achieve and that I can pass on my enthusiasm for learning now, and as you embark on your own formal education journey in a few years time. xvi

17 Contents Abstract... ii Anthology of Publications... vi Keywords... viii List of Figures... ix List of Tables... x List of Abbreviations and Glossary... xiii Statement of Original Authorship... xv Acknowledgements... xvi Contents... xvii 1 Introduction Introduction Research aims and questions Significance of the thesis Structure of the research included in the thesis Literature review Introduction Adolescence to young adulthood Help-seeking behaviour in youth Youth specific mental health services Disengagement from youth services Functional concerns in help-seeking youth Employment and education Social/relationships Factors influencing role function in youth Demographic factors Mental ill health Affective disorders Distress Psychotic disorders Psychotic-like experiences xvii

18 2.6.3 Substance use and risk taking Alcohol Cannabis and other drugs Summary of role function and association with cognition Measuring function Conclusion and future research Methods Introduction Setting and participants Procedure Ethical approval Materials Study one Study two Study three Socio-demographic variables Vocational functioning Neurocognitive performance Intra-Extra Dimensional Set Shift Rapid visual Information Processing Spatial Working Memory Paired Associates Learning Information Sampling Task Psychological wellbeing Kessler Psychological Distress Scale Community Assessment of Psychic Experiences Mental health diagnosis Youth Risk Behaviour Survey Exploring functional concerns in help-seeking youth: A qualitative study Preamble Manuscript Abstract xviii

19 4.2.2 Introduction Methods Results Discussion Commentary Service disengagement and help-seeking from youth mental health services:... predictors and implications for practice Preamble Manuscript Abstract Introduction Methods Results Discussion Conclusion Commentary Comparing predictors of part-time and no vocational engagement in youth primary mental health services: A brief report Preamble Manuscript Abstract Introduction Methods Results Discussion Conclusion Commentary Prediction of vocational participation and global role functioning in help-seeking young adults, from neurocognitive, demographic and clinical variables Preamble Manuscript Abstract xix

20 7.2.2 Introduction Methods Results Discussion Commentary Setting measureable goals with young people: qualitative feedback from the Goal... Attainment Scale in youth mental health Preamble Manuscript Abstract Introduction Methods Results Discussion Conclusion Commentary Focusing on function in youth mental health: Could goal setting help engagement? Preamble Manuscript Abstract Introduction Methods Results Discussion Conclusion Commentary General Discussion Summary and strengths Limitations Clinical implications and future research References Appendices xx

21 Chapter 1: Introduction Adolescence and young adulthood is a critical developmental period when substantial neurobiological, hormonal, occupational and social changes occur [3-7]. These changes allow individual opportunities for personal growth and accomplishment however, they also increase vulnerability to distress and difficulties with adjustment [8-11]. It is not until people transition into some of the adult roles by early to mid 20 s that the high rates of psychological distress stabilise and increased behavioural constraint is observed [12-14]. Many major mental illnesses have prodromal stages in adolescence [7, 15], and 75% of all lifetime cases of mental illness are present before 24 years [16]. Mental illness accounts for about 50% of the total disease burden for young people in Australia [1]. There has been considerable policy and fiscal investment in early intervention services both in Australia and internationally [17-19]. The aim of service providers and policy makers is to reduce the burden of disease of mental illness during this developmental period, and subsequently to reduce the risk of long term illness and disability [15, 19]. A number of unresolved issues surrounding intervention and pathology in young people who may be seeking help for psychological issues but who do not have a diagnosed mental illness exist. There has been a plethora of media reports and discussions about reducing the barriers to help-seeking for young people and understanding the needs of the youth population as a whole [19-23]. Very little has been reported on the functional needs and concerns of the help-seeking cohort as opposed to the wider youth population. Research that is available has used large data sets reporting only one reason for help-seeking [24]. Greater clarity around this issue would help to ensure that treatment approaches validate the experiences 1

22 of young people and are responsive to mental health recovery needs. It would allow for greater examination of measures used to report functioning to ensure they are relevant and appropriately capture the experiences of the young people seeking help [15, 25, 26]. Although there is a sound understanding of the impact of severe mental illness on the developmental trajectories of young people, there is less clarity about the impact of subthreshold symptoms or psychological distress [20, 27-30]. The evidence is inconclusive about the impact of mild mental health problems on young people. However, the assumptions are that the impact of even mild psychological problems during adolescence can disrupt cognitive development and substantially impact on identity formation, educational and vocational achievement, and limit opportunities and the establishment of adult roles [6, 7, 10, 19, 31]. Young people experiencing distress and emerging mental illnesses are particularly vulnerable to employment instability with rates of unemployment or NEET (Not in Education, Employment or Training) between 19% and 29% [24, 32], compared to 13% of year olds in the general youth population [33]. Young adults presenting to early intervention services are predominantly experiencing affective and anxiety symptoms (37-53%), high or very high levels of distress (69%) and substantial levels of disability, with 55% of year old males and 62% of similar aged females reporting at least one day away from their occupational role due to mental ill health [24, 34]. Research into psychosis and substance abuse has been the most thorough in demonstrating the prevalence and impact of neurocognitive deficits on functioning [30, 35-38]. Neurocognitive deficits in the ultra high risk and early psychosis cohorts have been identified as an independent predictor of functioning and a more stable predictor of long 2

23 term outcomes, including employment, than symptoms [28]. Unemployment in this cohort exceeds 40% [92], resulting in significant personal and societal disability burden. Employment outcomes in people with a range of health issues have also been associated with neurocognitive functioning, although very few of the studies reviewed controlled for demographic and other relevant variables [43]. Considering the increased risk of developing a mental illness for those experiencing reduced psychological wellbeing, neurocognitive changes in the prodromal stages of major mental illnesses, and the reduced rates of vocational role participation, further examination of the association between neurocognitive and vocational role function is warranted. Research with this focus may assist to clarify the potential impact of these experiences on developmental trajectories and improve understanding of when these experiences impact on real work outcomes and therefore require early intervention. Goal setting is a valuable clinical tool used by many professionals working in the health field to encourage people to synthesise their needs and to identify outcomes meaningful to them as individuals [25]. Goal setting is championed by those supportive of recovery-oriented mental health service provision [44, 45], and if goals are specific, measurable and challenging, goal setting can motivate behaviour change and improve functional outcomes [46, 47]. This may be particularly important for young people who are traditionally very difficult to engage in mental health services [20, 21]. There are a number of tools to support effective goal setting including Goal Attainment Scaling [48] however, the feasibility and acceptability of using this tool with young people is unknown. It is also unknown if effective goal setting will improve engagement in youth primary mental health services or provide the basis for evaluation of client-centred outcomes. 3

24 1.2 Research aims and questions This programme of research aimed to elucidate i) functional concerns of help-seeking young people, (ii) the impact of neurocognitive capacity on vocational role function, and (iii) current experiences of goal setting and the acceptability of formal goal setting within this population. Therefore the research questions addressed in this program of research among young people seeking psychological help are: 1a. Why are they seeking help and what are their functional concerns? 1b. What demographic variables predict individual presenting issues and service disengagement? 2a. What are the rates of vocation participation and are correlates of not working or studying also correlated with those participating in part-time employment or study? 2b. Is neurocognitive capacity correlated to the level or quality of vocational role function in young people post-secondary school? Does this association remain after controlling for relevant demographic and clinical variables? 3a. Is formal goal setting using the Goal Attainment Scaling acceptable to young people and does it elucidate client desired treatment outcomes? 3b. What are the content and quality of goals routinely set during service assessment and engagement? 1.3 Significance of the thesis This research is important to the field of youth mental health by outlining reasons for helpseeking, concerns relating to role function, and exploring predictors of individual presenting issues and vocational role engagement. It extended the research exploring correlates of vocational role functioning, by examining the potential association neurocognitive capacity 4

25 may have on employment and/or educational engagement. This thesis also provided the first empirical information on rates and predictors of service disengagement. Detailed information about the needs of young people accessing early intervention services can support clinicians and service managers to evaluate the services they offer against consumer needs and, if appropriate, develop more assertive or targeted treatments for subgroups more vulnerable to social exclusion or service disengagement. Lastly, this research explored the use and quality of goal setting in youth mental health services and its potential correlation with service engagement. This doctoral program of research has been the first to report service-user feedback on the acceptability of formal goal setting, specifically the Goal Attainment Scaling. It is hoped this final section of the thesis will provide clinicians with evidence and structure to help evaluate their use of goal setting, and strengthen their practice by using this clinical tool to identify meaningful, clientdriven outcomes. 1.4 Structure of the research included in thesis There are three inter-related themes in the body of this thesis that were addressed through data collected using three different methods. A primarily sequential, mixed methods design was used in this program of research. Study one was completed first and provided valuable qualitative information which refined the research questions for subsequent studies. Studies two and three were conducted in parallel to ensure adequate recruitment and data collection time. Study one addressed aims 1a and 3a; study two addressed aims 1b, 2a and 3b; and study three addressed aim 2b (Figure 1.1). 5

26 Figure 1.1: Structure of program of research Study Theme Aim Manuscripts Thesis Literature review identifying topics to be investigated Study 1 Qualitative design Study 2 Retrospective cross - sectional Study 3 Prospective crosssectional Functional concerns, reasons for helpseeking Vocational role function, correlates and predictors Goal setting and goal quality Aim 1a Aim 1b Aim 2a Aim 2b Aim 3a Aim 3b Manuscript 1 Manuscript 2 Manuscript 3 Manuscript 4 Manuscript Manuscript 5 Manuscript Manuscript 6 Chapters Chapter 4 Chapter 5 Chapter 6 Chapter 7 Chapter 8 Chapter 9 Chapter 10 Chapter 1 provided an introduction to the thesis and the rationale and significance for the program of research. Chapter 2 provided a critical analysis of the relevant literature on adolescent and young adult development, help-seeking behaviour, functional concerns reported in help-seeking youth and potential factors influencing role function. Relevant literature has also been synthesised in subsequent chapters within the manuscripts presented. Chapter 3 described a brief overview of the methods used for each study within this doctoral program of research and provided greater detail of materials used that, due to word count and editorial preference, were not able to be reported in the manuscripts. The first theme in this thesis focused on the presenting issues of young help-seekers. The first investigation was a qualitative study exploring reasons for help-seeking (Chapter 4). This study with ten young people revealed that almost all were seeking help for support 6

27 with emotional management. As well as difficulties with emotions, the young people were also concerned with relationships, employment and risk-taking behaviours. The younger cohort (12-17 year of age) in this study reported concerns with relationships and social role more frequently than the older cohort (18-25 years of age), who were more likely to report concerns with employment. The manuscript reporting the results of this investigation was published in Early Intervention in Psychiatry. The second investigation reported in Chapter 5 explored factors predictive of individual presenting issues and disengagement from youth early intervention services. This retrospective cross-sectional study of 283 young people attending youth mental health services demonstrated results congruent with the findings reported in study one (Chapter 4). Younger age was predictive of presenting with social or relationship issues and older age was predictive of issues with work and study. Reduced vocational participation was also predictive of premature service disengagement. A manuscript reporting the results of this investigation has been submitted to a peer-reviewed journal. The second theme in this thesis narrowed the focus of the research from identifying all presenting issues to specifically explore predictors of vocational role function. Chapter 6 reported data collected during the retrospective cross-sectional study (study two), identifying the rates of young people not in employment or study and predictors associated with levels of vocational participation (full-time, part-time). This investigation identified that young people disengaged from work and study also experience other indicators of disadvantage such as a history of drug use and reduced educational attainment but this 7

28 these associations are not observed in those participating part-time. A manuscript reporting the results of this investigation is in press with Early Intervention in Psychiatry. The third empirical investigation examined the role of neurocognitive capacity on vocational role functioning, controlling for relevant demographic and clinical variables. To examine this, a prospective cross-sectional cohort study (n=107) was undertaken. The findings revealed that although a number of neurocognitive outcomes were related to vocational role functioning, once demographic and relevant clinical variables were controlled, only the strategy score on a spatial working memory task remained significantly associated. A manuscript reporting the results of this has been submitted to a peer-reviewed journal. The next two chapters (8 and 9) form the final theme in this thesis. This theme considered the identification of functional concerns using goal setting as a potentially clinically useful process. One of the challenges for clinicians and service managers is the utilisation of outcome measures that are meaningful for both individuals and for service evaluations. The use of goal-based outcomes has potential as a familiar clinical tool to provide a measure meaningful to the young people attending mental health services. There is a paucity of literature reporting the acceptability of formal goal setting from the service-user perspective, and no empirical evidence describing the current quality of goal setting in youth early intervention services. Chapters 8 and 9 have addressed these issues. Chapter 8 presented a published manuscript of a qualitative study exploring the acceptability and feasibility of using the Goal Attainment Scaling in youth services. This investigation utilised qualitative data collected from the young people (n=10) who 8

29 participated in the study reported in Chapter 4. To consider if formal goal setting was acceptable for young people, participants identified one area of concern that they developed into a goal for therapy. Every participant was able to identify a goal and engaged positively in using the Goal Attainment Scaling as a formal goal setting tool. A number of participants discussed their desire to have ownership over the physical location of the goal sheet and how they would use this as motivation for goal attainment. The manuscript reporting the results of this investigation was published in the British Journal of Occupational Therapy. Knowing that young people have reported positive experiences with goal setting, the next investigation (Chapter 9) analysed data collected during the retrospective chart audit to identify the rates and correlates of goal setting in youth services. One hundred and sixty six goals were set by a sub-group of 74 young people. The content of these goals was analysed to determine whether the goals set were specific and measureable. This study found that the majority of young people set goals during their initial service assessment, but very few of the goals were specific or measurable, limiting their potential use as an outcome measurement tool. The manuscript reporting the results of this has been submitted to a peer-reviewed journal. Chapter 10 includes a discussion of the clinical implications for identifying difficulties in role function with young people and the use of goal setting to develop client-driven outcomes. The limitations of the research, the contribution of the thesis to the body of knowledge and recommendations for further research are synthesised in this final chapter. 9

30 Chapter 2: Literature review 2.1 Introduction Mental illness is the highest burden of disease in adolescence and young adults. In 2003, mental disorders accounted for around 50% of the total disease burden for people aged years in Australia [1]. Many major mental illnesses have prodromal stages in adolescence with clinical onset in mid-late adolescence/young adulthood [7, 15]. Depression alone has been reported to affect one in five people before the age of 18 years [49, 50] and 75% of all lifetime cases of mental illness are present before 24 years [16]. Adolescence and young adulthood is a critical developmental period where even mild mental health problems can have a major effect on adult life [6], substantially disrupting educational and vocational achievements, impacting on identity formation, limiting opportunities and disrupting the establishment of adult roles [31]. The junction between child and adulthood is acknowledged to be behaviourally one of the most challenging for parents [7] and a time of greater psychological vulnerability and stress sensitivity for the young person [7, 10]. Substantial neurobiological [3-5] and hormonal [7] changes occur between the ages of years as well as vast changes to social, occupational and community roles and expectations [51]. These factors culminate to allow new opportunities and freedoms however, they also impact on psychopathological vulnerabilities, with change in almost all areas of a person s life [8-10]. This period of neurobiological, personal and social change yields higher rates of distress and difficulties with adjustment, more than at any other time in the lifespan. Adjustment difficulties can manifest as high rates of self-harm and suicidal ideation and action [15, 36] which do not appear to stabilise until people transition into some of the adult life roles [12]. 10

31 There has been substantial fiscal and policy investment in youth mental health services over the last 15 years [17-19, 52] resulting in the emergence of national co-ordinated early intervention services in Ireland and Australia with more localised services elsewhere in the developed world, aimed at reducing the burden of illness and improving accessibility to youth-friendly support [15, 52, 53]. It is considered particularly important to reduce the impact of a disorder during the transition phase from youth to adult with the belief that interference with the person s ability to accomplish essential development tasks can have a lifelong negative impact [17]. For example, mental disorders such as anxiety, mood and conduct disorders are significant predictors of educational failure at both secondary and higher education level [31], impacting on future social and vocational experiences. This review provides an overview of contemporary youth mental health research with a focus on the reasons young people seek help, the functional difficulties help-seekers may be experiencing and the proximal factors impacting on function. The review then concludes with a discussion on the focus for future research. 2.2 Adolescence to young adulthood Young people aged years are developmentally in a period of transition from childhood to adult life with markers of this transition being finishing education, commencing employment, leaving their home of origin and experimenting with normal adult activities such as developing intimate relationships and using alcohol [2, 11, 15, 51, 54]. This normal transition of life roles and expectations is considered one of the most critical as it involves simultaneous social role, contextual and individual changes which appear to increase the mental health vulnerability of young people [10, 11, 20]. Partly for these reasons, most 11

32 mental illnesses emerge during this time [15, 16]. For most individuals, this transition occurs without significant disruption to psychopathology and mental health [7, 10], and by early adulthood (mid 20 s) personality traits stabilise with a decline in negative affectivity and an increase in behavioural constraint [13, 14]. This transition from child to adult allows opportunities to flourish as opposed to the potentially homogenous expectations of formal secondary schooling [8]. For others, however, the trajectory of functioning and adjustment in adolescence when continued into young adulthood can consolidate or manifest maladaptive psychological functioning that was subthreshold in adolescence [7, 10]. Unfulfilled expectations about educational attainment, employment, marriage or relationships and parenthood have all been identified as risk factors for substance use and depressive symptomology [11, 12, 55, 56]. 2.3 Help-seeking behaviour in youth It has been reported that all young people need support in the development of independence and adult role attainment [17]. For most this is informal peer support [21, 57] or the availability of at least one good adult [58], and most young people thrive into adulthood. However, for those that flounder and experience distress beyond the scope of what informal supports can offer, or have supports that are unhelpful or destructive, formal help can provide necessary counsel. Unfortunately, relatively low rates of professional service use compared with reported high levels of need have been a concern and have resulted in strong calls for research and innovative service delivery [17, 20, 58, 59]. Prior to the development of youth-specific services, studies describing rates of help-seeking reported that 10-30% of young people who score in the clinical range for mental health 12

33 problems have sought professional help [20, 21, 36, 57, 60]. Irish studies report 20% of young adults (17-25 years) and 9% of year olds felt they needed professional support but did not seek it [58]. In an Australian national survey, parents reported barriers to obtaining help as being too expensive (50%), did not know where to go, thinking they could could handle the problem, asking for help but not receiving it (40-50%) and having to wait a long time (~36%). Less common reasons were that their child did not want to attend and service too far away (25%), and a belief that treatment would not help [36]. Only 6% of parents reported stigma to be a significant barrier to obtaining treatment [36]. In contrast a study of university students found that 27% of participants identified stigma as a reason for not seeking help [61], and in other studies, young people report being embarrassed to talk about problems as a barrier [6], suggesting a disparity between parental beliefs and the experiences of young people. Negative experience when seeking help may also act as a barrier for future help-seeking, reporting they sought help in the past that they felt was not useful or that their problems were not taken seriously [6]. Problems with social functioning of high school students and vocational functioning with those over 18 years of age have been identified as a cause of concern and distress in young people [8, 21]. Neither of these studies reported if the concerns of the help-seeking group were different to the broader youth population. Analyses of large data sets have identified mental health and behavioural concerns as the main reason for young people to seek help [24, 52]. Other reasons for seeking help have been identified as school work and vocational issues, relationships, alcohol and drug use, and physical and sexual health [24]. 13

34 2.4 Youth-specific mental health services Adolescence is a time when the disease burden of mental illness is at its highest and opportunities for early intervention may be at their peak however, access to flexible responsive mental health services is limited, primarily resting on specialised, crisis driven tertiary mental health services [53]. Under the weight of epidemiological and service access information, a number of mental health services have embarked on a reform of youth services and developed community, no wrong door early intervention services [59, 62]. Australia and Ireland have taken a national approach to this with the headspace and Jigsaw services [53]. Canada looks likely to follow suit with the ACCESS service transformation [63]. Although engaging a similar philosophy, all services are being developed and shaped by the constraints of their respective governments and funding arrangements. Regardless, there are some key principles which proponents of these services see as vital, including youth involvement at all levels, targeting the age of developmental transition and emergent risk of mental illness at years, social inclusion and vocational outcomes as core targets, and youth friendly and stigma-free environments [53]. There has been some criticism about the rapid expansion of headspace services in Australia and the outcomes being reported [64, 65]. In Australia, data on rates of help seeking have demonstrated a 230% increase in young people accessing general practitioner mental health services and a substantial increase in young men seeking help [66]. However, there is debate as to how attributable increases in help-seeking are to the headspace model [67-69]. Most persistent are criticisms of the effectiveness of the service in improving psychological and functional outcomes [65, 70]. 14

35 2.4.1 Disengagement from youth services Very little is known about the proportion of young people who seek help from youthspecific health services but do not follow through with treatment, their reasons for disengagement, and whether there are any common demographic or clinical features of this cohort. Research on disengagement in general mental health services is inconsistent, due to a lack of a standardised definition and measurement of disengagement [71]. Approximately 30% of people with an early episode of psychosis disengage from services within the first months of receiving treatment, and most of these disengage in the first 12 months [72]. Common predictors of young people dropping out of tertiary mental health services include negative stereotyping of mental illness, poor insight into the need for treatment, and substance abuse [71, 72]. It is inappropriate to compare the experiences of tertiary psychosis services to the broader, youth early intervention primary health services, although the consumer age is similar, because the broader population has lower levels of disability and different mental health and functional needs. The rates and reasons for disengagement in primary mental health services is unknown, particularly where young people are experiencing distress or functional concerns but may not (yet) meet the criteria for a mental health diagnosis. 2.5 Functional concerns in help-seeking youth Overwhelmingly, young people are seeking help from contemporary youth mental health services for support with emotional issues and they report concerns with symptoms of depression, anxiety, stress, anger and self-harm [52]. There is some evidence to suggest an age related correlation with functional concerns. For example, help-seeking young adults (18 years and older) may have greater concerns with work and study than their younger 15

36 counterparts, who have reported greater concerns with social functioning [58]. However, research focussing only on the main reasons for help-seeking may inadvertently underrepresent the true extent of functional problems, as attendees may have multiple reasons for seeking help. The prompt for active engagement with youth services is likely to be related to issues such as elevated anxiety or depression symptoms or distress, however psychological reasons commonly co-exist with functional issues to seek help, such as difficulties with social relationships or work and study. For example only 1.8% of young people identified vocational reasons for accessing a youth mental health service, but demographic data from that study revealed that half of participants aged years were looking for work [73]. Higher rates of functional issues may be more reflective of the needs of these young people and understanding these issues may assist services to refine intervention and improve engagement. For the purpose of this section of the review, functional concerns have been constrained to concerns with role functioning in the areas of employment, education and relationships, as difficulties with these roles have been reported in the help-seeking literature and been correlated with higher rates of substance use and depressive and anxiety symptoms in general youth populations [11, 12] Employment and education The exploration of educational and employment opportunities by young people transitioning from secondary schooling to higher education, training or employment is a normal and healthy part of emerging adulthood [2]. However, young people are vulnerable to instability in the labour market [74]. Instability in employment can have a detrimental effect on income, occupational status and career satisfaction later in life so instead of successfully exploring opportunities, vulnerable young people may be left floundering in the 16

37 labour market [75]. Ongoing unemployment in young people can reduce quality of life, increase ill health and social exclusion and is associated with severe levels of disadvantage through financial strain and poverty [76-79]. Those with mental illness or disability may be particularly vulnerable when faced with challenging economic circumstances [80]. Young people experiencing distress and emerging mental illnesses experience employment instability, with rates of unemployment or NEET (Not in Education, Employment or Training) being between 19% and 29% [24, 32], compared to 13-15% of year olds in the general youth population [33, 81]. However, employment is not the sole indicator of vocational success. Varying levels of educational engagement and the adequacy of employment combine to give a more realistic picture of vocational participation [82, 83]. Underutilisation of young people in the labour market is discussed almost solely in terms of employment, with those in part-time education or work often not being reported [84]. The non-linear flow of young people from education to employment or a combination of study and employment is the reality of contemporary youth labour markets [83]. While previous research has reported high rates unemployment in young people who seek psychological help, the extent of their underutilisation in employment and education is unclear. Young adults presenting to early intervention services are experiencing substantial levels of disability, with 55% of year old males and 62% of similar aged females reporting at least one day away from their occupational role due to mental ill health [24, 34]. Factors that influence vocational engagement are both individual and regional or economic (e.g. employment demand) [76]. Level of educational attainment, gender, disability, 17

38 relationship status, age, workplace experience and social networks have all been identified as factors that impact on employment in the general youth population [76]. Evidence identifying individual risk factors in the help-seeking youth population is limited, although being an older male (20-25 years old), criminality and substance use have been found to be associated with worse vocational outcomes [32]. Contrary to the general population, postsecondary educational attainment and ethnicity have not been found to be significantly correlated with vocational engagement in help-seeking youth [32]. The extent to which young people seek help for work and study related concerns is not well reported. As discussed, studies identifying one main reason for help-seeking may mask underlying functional issues, as young people may be inclined to report their acute psychological concerns over issues relating to role function. The largest review of headspace data from 55 centres, reported that almost half of the sample was looking for work [73] but only 1.8% reported vocational reasons as their main reason for help-seeking. The reporting of this data without greater context may potentially narrow the focus of care, prioritising short term gains in symptom or distress reduction over longer term improvements in functioning. Reports from the Jigsaw youth service in Ireland did not limit data to main reasons for presenting, and reported academic problems and school avoidance to be a concern for 9.6 and 9.7% of the sample respectively [52] Social/relationships In the general youth population relationships are both a significant issue of concern and a protective mechanism. In Ireland, family is the fourth significant stressor reported by young adults (17-25 years old) and the second for adolescents [58]. In Australia, this is also the case, with 24% of, mostly adolescent, responders to a national survey reporting family 18

39 conflict as an issue of concern, making it the fourth most frequently reported issue [21]. Friendships are also a significant stressor, with issues such as bullying and emotional abuse reported by 23% of adolescents (12-19 years) [21, 58]. Perhaps friendships are of such concern because they are also what young people value and use as the most common coping strategy when things are tough [21, 58]. The group of young people who seek formal help report slightly lower rates of concern with interpersonal relationships than the general adolescent population, with family problems and parent/youth conflict reported by 20.9% and 16.4% of the overall population seeking help from Irish youth mental health services [52]. Though the age of those who reported this issue is skewed towards the younger cohort (19.6% of year olds) whereas, relationships were their primary reported reason for presenting to headspace in 7.8% of the year old group [24]. Other functional skills such as maintaining safe housing and financial capacity do not feature among the most commonly reported reasons for attending services, but they remain a concern for a section of vulnerable youth. For example, 10.3% of young help-seekers in Australia reported accommodation was an issue, 2.4% perceived themselves at risk of being homeless, and 0.7% were currently homeless [24]. Young adults in Ireland reported money as the second largest stressor, with 45% reporting feeling often stressed by their financial situation, and another 14% were highly stressed [58]. Financial stress seems a feature of modern life however, young people, and particularly students, report concerns with money impacting on health and wellbeing, with up to 25% of those under financial stress reported going without food and other necessities [85]. These issues are intrinsically linked with employment, educational and social experiences, and particularly family relationships. Unemployed young people also reported concerns with safe and adequate housing [78], in 19

40 Australia, only 2% of homeless young people are employed in full-time jobs, with 22% never having worked. 2.6 Factors influencing role function in youth For a lot of people, adolescence is accompanied by an increase in psychological distress, feelings of awkwardness, an increase in risky behaviour and more frequent social conflicts [7].For most these feelings are transient, and the emotional rewards and learning from the progression to adulthood is positive [8]. However this is not always the case. One large prospective study identified 7% of young people reporting high levels of wellbeing at 18 years but relatively low levels at 26 years [8]. Psychological wellbeing in adolescence has been examined in a number of ways. Psychological distress [60], presence of psychotic-like experiences [61], alcohol and drug use [86], risk taking behaviour [21] and lower levels of functioning than expected [11] have been associated with poorer psychological wellbeing. Some elements of wellbeing such as risk taking can be observed and measured objectively whereas others, such as psychological distress are primarily a personal and subjective emotional reflection [87]. This next section of this literature review examines underlying factors associated with role function in young people, particularly social and occupational function. The focus is on dynamic factors including mental health diagnosis, experiences of subthreshold symptoms, such as psychotic-like-experiences and heightened distress, and behavioural issues such as substance misuse. Cognitive deficits have been identified in a range of these issues including some mental illnesses and substance use and are included throughout the next section of the review. 20

41 2.6.1 Demographic factors A review of the dynamic factors associated with function would not be complete without a brief discussion of the static or demographic characteristics that have also been associated with role function. Factors such as age, gender, socioeconomic background and family history of mental illness have all be associated with social and occupational dysfunction [9] [32, 58, 88-90]. It is no surprise that age impacts heavily of vocational role function, as transition from adolescence to adulthood is a time of role development and competence. Developmental skill acquisition aside, younger adolescents have the protection of formal secondary schooling where role exploration is often restrained by the education system [10]. In almost all OECD member countries, young females are more likely not to be in employment or education [91]. However, in Australian studies focused on help-seeking young people males were more likely to be NEET [32]. The inconsistent results are likely to be a result of the inclusion of females who are in carer roles in the OECD data [32], and as any parent can attest, they are therefore not without a meaningful role. Another factor could also be the expectations on young men as workers. If they are unable to fulfil this role, this may impact on their psychological wellbeing such as increasing risk of suicidal behaviours [90] and therefore drive a presentation to youth mental health services. Although useful to refine target populations for interventions or as 'red flags' for vulnerability to dysfunction or mental illness, factors such as age, gender and family history are not 'risk factors' that can be mitigated by the time an individual engages with youth health services. 21

42 2.6.2 Mental ill health There is no doubt that young people who experience any form of mental disorder are more likely to experience educational failure [31] and days out of work [34]. With three quarters of all lifetime mental illnesses emerging in adolescence when adult life-skill development is emerging, it is little wonder the burden of mental disease is so high in young people. People with severe mental illnesses, such as psychosis, that emerge in adolescence and early adulthood have been reported to have particularly high rates of unemployment, exceeding 40% [92] Affective disorders Young people at risk of developing psychosis who do not transition to psychosis often have the final diagnosis of an affective spectrum diagnosis such as depression, bipolar disorder and adjustment disorder [40, 105]. This suggests that cognitive functioning is not only impaired in those with psychosis (or ultra high risk of psychosis) but may also be impaired in people displaying symptoms of disorders more common in the general population, such as depression and anxiety. Similar to psychotic disorders, age of onset for mood disorders is usually in childhood or adolescence [16, 128]. Australian data suggest up to 7% of year olds will experience depression in any 12 month period [1]. Using self-report inventories, an Italian study of university students identified that mild to severe depression (13.9%) and anxiety (26.9%) were common [61]. Neurocognitive deficits in adults experiencing unipolar depression is reasonably well understood however, there is a paucity of data published on the association in adolescence and younger adults [ ]. What has been published has produced contradictory results 22

43 with concerns expressed regarding sampling [131]. Studies have typically indicated cognitive deficits in executive function [129, 130], impulsivity in decision making [133] and verbal working memory [134]. Preliminary research with young people who have a bipolar disorder indicates deficits in sustained attention, learning and recall, spatial reasoning and executive functioning after resolution of their first manic episode [135]. Researchers have concluded that deficits in cognition are present at onset of bipolar disorder and cannot be attributed solely to a longer term progression of illness [135]. The functional impact of neurocognitive deficits in adolescents and young adults with mood disorders requires attention [129, 130, 136]. Although there is general acknowledgement that a major depressive disorder in adolescence is a risk factor for future functional impairments [132, 137], literature articulating short and long term functional impact of a mood disorder is limited. One study reported boys with symptoms of depression to be more socially withdrawn when compared to girls with symptoms, indicating worse short term social functioning [137]. However, a longer follow up study (15 years) found females who had experienced depression in adolescence had greater difficulties with intimate relationships such as intimate partner violence, single parenting and divorce, than female peers or formally depressed males [138]. Although there are limited studies, the impression is that adolescents with symptoms of anxiety, depression and bipolar report more difficulties with their academic studies and lower subjective wellbeing and self esteem [136, 137] than healthy peers. Boys who were in remission reported more behavioural, academic, social and psychological problems than boys with no symptoms at both baseline and at five year follow up. [137]. Neither of these studies completed neurocognitive testing, which was recognised as a limitation to understanding the true underlying causes of functional 23

44 disability in this population [136, 137]. Models such as IPS (Individual Placement and Support) have a strong evidence base with populations experiencing severe mental illness and young people with first-episode psychosis [139, 140] however, effectiveness in the general youth help-seeking population is unknown Distress A significant association between risk-taking behaviour and psychological distress often emerges at extremes of risk-taking behaviour such as dependence and harmful use [60, 86]. Psychological wellbeing however encompasses more than engagement in risky behaviour, and it seems more likely a young person will report distress with their inability to realise role attainment and be much less aware of the cognitive challenges they may be experiencing. An Australian national survey of year olds (n~48000), conducted in 2009, described the main reasons for psychological distress and concern as family conflict, substance use and mental health issues, such as coping with stress and body image [21]. However this study had minimal representation (2.1%) of young adults over 20 years, and did not comment on whether participants over 20 years old had different concerns and reasons for distress. Schulenberg, Bryant and O Malley (2004), reviewed data from 3518 American year olds who had participated in three waves of the Monitoring the Future study [8]. They examined the relationship between wellbeing and seven domains of functioning. Each individual was assigned a score of 3 (succeeding), 2(maintaining) or 1 (stalling) for each developmental task at each stage, and wellbeing was rated on self-esteem, self-efficacy and social support. There was a significant correlation between overall developmental task success in work, romantic involvement and citizenship, and greater wellbeing [8]. The 24

45 difference in reporting from the two studies appears to suggest family relationships may play a larger role in wellbeing in early and mid-adolescence, while success with romantic and peer supports is more significant in late adolescence and early adulthood. Work also featured heavily in the wellbeing of the older age group, but employment concerns did not rate a mention in the study with predominately school-aged youth [8, 21]. Behavioural and adjustment problems in adolescence do not inevitably assume ongoing mental health disorders into adulthood, but the risk for later disorders is significantly greater among this group [7]. Young people experiencing homelessness, for example, experience much higher rates of psychological distress, and this inability to maintain accommodation is a risk factor for youth mental illness [19]. Although psychological distress does not necessarily imply the presence of mental illness, people with high or very high levels of distress are likely to have experienced a mental illness within the previous 12 months [141] Psychotic disorders Schizophrenia and other psychotic disorders are both acutely and chronically disabling with devastating personal, family and community consequences [27, 28]. Approximately 18% of adults with schizophrenia report initial onset prior to 18 years of age [39, 95], though age of onset peaks just prior to 25 years [95]. The early age of onset of psychotic disorders coincides with the considerable neurobiological changes also occurring at this time. In light of this, researchers have focused on identifying potential neurocognitive deficits evident in psychotic disorders, particularly schizophrenia [96, 97], as well as indentifying these deficits prior to the onset of overt positive symptoms [35, 39-41, 96, 98]. 25

46 It is now widely accepted that prior to diagnosis, people experiencing these disorders may also experience impairments in executive functioning [30, 40, 99], sustained attention [30, 100] and processing speed [30, 35, 40, 96, 99, 101], and decreased working and verbal memory [30, 35, 40, 96, 102]. Twin studies examining academic records in which only one sibling developed schizophrenia discovered a divergence of results at about 12 years of age, preceding clinical onset of the illness by up to 10 years [42]. The cognitive deficits and deterioration in functioning combined with other factors can indicate an increased risk of development of a psychotic illness (termed the prodromal phase ) [103, 104].. Neurocognitive research in the ultra high risk and early onset schizophrenia in adolescence has reported cognitive deficits such as processing speed and executive functioning as being independent predictors of everyday living scores, explaining 18-21% of the variance in functioning [99, 104].. Deficits in cognition in the prodromal phase are not as severe as in people already afforded a psychotic diagnosis, including those at first presentation of psychosis [40, 96], lending hope that early intervention could reduce further decline in cognitive functioning [101]. The neurocognitive deficits seen in the prodromal phase of the illness may have more functional repercussions in adolescents with early-onset psychosis than in adult-onset, as they interfere with a period of time crucial for neurobiological, social, emotional, and academic development [35, 39, 100], as discussed earlier. These impairments could result in more disabled occupational functioning, social attainment and independent living [30, 107, 108]. Preliminary research has shown significantly worse premorbid functioning and a longer duration of untreated psychosis in early onset psychosis [39, 108]. A chart audit of 636 patients entering an early psychosis specialist service showed no difference in 26

47 occupational outcomes between adult and adolescent onset at discharge from service (total length of program was 18 months) [39]. The authors of this study acknowledged that this research needed to be replicated over a longer time period to confirm this result, and they also did not provide information on early discharge/drop outs, making it difficult to determine the true follow up time [39]. The short maximum follow up period of this programme potentially masked the true long term functional outcomes of these individuals since, cumulative relapse rates for first-presentation psychosis are as high as 82% within five years [109]. Relapse rates rise dramatically in the second year, from 16% in year one to 54% in year two [109]. Little is known about the functional outcomes of young people who may present at risk of psychosis that do not transition to experiencing a psychotic disorder. One study followed up people that did not transition over a 2.5 year period, and indicated significant improvements in positive and negative symptoms, and social and role functioning[118]. Although there were improvements in functioning, this group remained at a lower level of functioning than non-psychiatric controls [118]. This result appears to suggest that prodromal symptoms of psychosis may be associated with ongoing disability for at least 2.5 years, despite the absence of attenuated positive symptoms [118]. It is not known if this level of disability would reduce further if the follow up period were longer, or if this group would continue to have lower-than-expected level of functioning throughout their lifespan. For most high-risk individuals who do not convert to psychosis within 12 months, the impairment in psychosocial functioning is more stable than symptoms and is a robust predictor of clinical outcome [28]. However, as noted in the paper on this study, functional 27

48 impairment should not be equated with ongoing psychosis risk, as higher rates of comorbid mood and anxiety disorders were also observed in functionally impaired individuals [28] Psychotic like experiences (PLEs) Subclinical psychotic-like experiences have been recorded in the general population at prevalence rates of about 8% [119, 120], with higher rates in adolescence (28%) and young adults (20%) [61, 115, 116, 121]. Psychotic experiences involve subtypes or components which can be experienced in isolation, be transient, and appear to have different clinical significance in predicting longer term mental health outcomes [61, 121, 122]. Traditionally, this has been broken into the positive, negative and depressive symptoms that have informed the development of the Community Assessment of Psychotic Experiences (CAPE) [115, 123]. A number of factor analyses of the CAPE in non-clinical adolescents and young adults have identified four subtypes of psychotic experience, including perceptual abnormalities (visual and auditory hallucinations), persecutory ideation (suspiciousness), magical thinking (occult, telepathy and grandiosity) and bizarre experiences (thought pervasiveness, influence and control) [61]. One study of Italian university students examined the association between these four factors and markers of psychological wellbeing and mental health, namely distress, depressive and anxiety symptoms, help seeking behaviour and global reduced functioning [61]. Persecutory ideation was the only factor that was associated with all the indicators of psychological wellbeing. However, this study involved only university students, which potentially skewed socioeconomic characteristics of the sample and impacts on the ability to generalise findings to the general youth population [61]. Of concern was the reporting in this study of overall levels of global function, with 40% of their total sample (n=997) reporting poor functioning using the General Health 28

49 Questionnaire-12 with the threshold value of 4 [61]. The authors then cited two other studies which identified poor global functioning using the same tool and threshold value in 39.5%, n=7125 adolescents [124] and 36.5% n=1289 adolescents and young adults [57]. The use of this tool for determining general functioning for young people needs further examination. It seems excessive that over a third of non-clinical youth populations would be considered to have poor functioning, and perhaps the threshold of 4 is more of an indication of the prevalence of mild mental illness [57] rather than function. At least one study has used the GHQ as a measurement tool of distress [125], though its primary purpose has been reported as detecting minor psychiatric illness [126]. By continuing with the use of this tool for the purpose of assessing function there is the risk of pathologising normal developmental insecurities, behaviours and experiences. Although there has been much discussion in the literature about the continuum of psychotic like experiences and psychosis [119, 124], there has been a paucity of studies exploring the relationship between PLEs and some of the key markers of disability, such as cognitive functioning, that emerge prior to a diagnosis of psychosis [122]. A large cross-sectional study examined the association between PLEs and sustained and divided attention in Korean high school students [122]. This study noted that self-reported high rates of PLEs predicted poorer divided attention outcome scores which were sustained after adjustment for depressive mood [122]. A UK study identified a significant association between poor general intelligence at 8 and 15 years and the presence of self-reported PLEs at 53 years [120]. There was also an association between poor adult General Health Questionnaire outcomes, childhood cognition scores and adult PLEs, although once PLEs were controlled for, the association between the General Health Questionnaire and cognition was no longer 29

50 significant [120]. In this instance, the experiences of general functioning may have been more dependent on proximal than distal factors. In a younger Korean sample sleep disturbances were found to be related to higher levels of PLEs, though no comment was made about the effects of the sleep disturbance on general health and functioning [127] Substance use and risk taking Risk taking behaviour has been reported as both a concern for young people [21] and as a natural part of the process of maturation to adulthood [86, 142, 143]. Risk taking holds a function for young people by allowing boundary testing and role exploration [86, 142], with only people at extremes of use (eg. alcohol abstainers and frequent users) showing significant differences in psychological distress [86]. Both legal and illegal substance use has been associated with positive psychological wellbeing as an expression of normal exploratory behaviour, and negatively where ongoing frequent and excessive use not only interferes with progression of developmental tasks [8, 86] but also has been linked to serious injuries including deaths [9]. A large review of risk and protective factors with substance use identified 27 exogenous and individual risk and protective factors [9]. The relationship between alcohol, marijuana and other drug use as it relates to psychological wellbeing and functioning is detailed below Alcohol Alcohol use is the most common drug and health risk behaviour among Australian adolescents (13-17 years), with 37% of surveyed young people reporting use and 20% reporting binge use [36]. There appears to be a strong relationship in young people between high emotional and behavioural problems and more frequent alcohol use [36, 58]. There is 30

51 little doubt that acute intoxication reduces cognitive ability across a range of domains [144, 145], however the longer term impact of alcohol use on cognitive ability is not clear [144, 146, 147]. The discrepancy in the results appears dependent on factors such as gender, age when alcohol use commenced, duration and frequency of use, length of follow up of study and scope of neuropsychological tests administered. Understanding the full impact of alcohol use on function is particularly challenging in this population, as the rate and level of maturation is not standardised [148]. However, It has been associated with lower-thanexpected educational attainment, unemployment and increased engagement in other risk taking and delinquent activities [37, 38, ]. A 10 year prospective study found those that used or experimented with alcohol at approximately 12 years of age did not necessarily mature out of destructive lifestyle choices by 23 years [149]. Conclusions around causal relationships between alcohol use and functional skills have been difficult to confirm, with most studies being cross-sectional which prohibits any conclusions about determinates of the association [9, 153]. Alcohol abuse, for example, influences future educational attainment, however this conclusion cannot discount the possibility that reduced educational attainment leads to substance use, or that both these outcomes reflect a common predisposing factor [55], even if they interact negatively on each another. The consensus in the literature appears to be that it is highly likely that early and significant alcohol abuse impacts on the neurocognitive development occurring in adolescence and subsequently affects longer term educational, vocational and social opportunities Cannabis and other drugs In Australia up to 25% of senior high school students reported using marijuana in the previous 12 months, with rates increasing up to 35% for the age bracket [154]. It is 31

52 the most commonly used illicit drug by adolescents and young adults [36, 155]. North American data revealed a trend in increased daily marijuana use in 2011 for adolescents in grades 8, 10 and 12 with 6.6% of young people in their final year of high school using marijuana daily or near-daily [155]. Marijuana use tends to peak in the transition years from adolescence to adulthood (18-25 years) [156]. Similar to alcohol use, concerns have been raised about the increased risk of regular exposure to the developing adolescent brain during this vulnerable time [153, 157, 158]. Knowledge about the impact of marijuana and other drugs on educational, social and occupational functioning is not definitive [55, 159]. Studies have indicated that regular marijuana use (weekly) influences high school completion rates and educational attainment [54, 56]. Marijuana and other drug use also negatively impacts on long term occupational attainment, however this association diminishes once level of educational attainment is taken into consideration [54, 159, 160]. Regular marijuana users in early adulthood report lower levels of work commitment, however if patterns of use reduce to being more experimental, levels of work commitment are on par with non-users [161]. Harder drug use appears to have a stronger link with poorer occupational outcomes and quality for up to 10 years post use [159]. One longitudinal study suggested that not being married by 33 years was associated with heavy adolescent marijuana use and an indicator for impaired social functioning [162]. This association also become non-significant in males once this result was controlled by high school completion rates [162], however, as stated, drug use influences high school completion rates [56] making definitive causal conclusions very difficult to draw. The association between frequent substance use and psychological distress is often implied through these examples of stunted developmental progression. A cross sectional study with 32

53 Chinese adolescents and the legal and socially acceptable use of tobacco identified an association between regular lifetime smoking and psychological distress, as assessed by levels of anxiety and hostility [163]. The authors reported this as evidence for the stressreduction theory of addictive behaviours [163], though without longitudinal studies comments such as this on causal relationships are speculative. A number of studies have identified current heavy adult marijuana users as having poorer cognitive functioning than their non-marijuana using peers [158]. Cognitive functions affected include memory [164], capacity for new learning [165], attention [164, 166], processing speed, visuospatial skills [167] and executive functioning [160, 166, 168]. Fortunately, in adults these deficits appear to remit once the user abstains for even a relatively short period of time (less than 28 days) [165, 169]. This, however, does not appear to be the case for people who commence regular marijuana use before the age of 16 years, with greater and more stable neurocognitive deficits in this population persisting after 6 weeks to 3 months of abstinence [ ]. Beyond this time period however, the potential persisting deficits and recovery processes are not known [158]. Like marijuana, solvents and hard drug use have also been associated with deficits in neurocognitive functioning [159, 173, 174]. Inhalation of solvents such as paint, glue or petrol for intoxication (often termed sniffing) is most common in young people [175], with higher rates in low socioeconomic groups and rural and remote communities where access to alcohol or drugs may be restricted by geography or regulation [173]. Dingwall et al. (2011) monitored cognitive functioning among petrol solvent users versus non-drug using healthy controls during an eight week residential treatment programme. Solvent users had 33

54 significant deficits in visual attention, visual motor and executive functions, visual learning and memory, and paired associate learning. Improvements were shown in paired associate learning after 6 weeks of abstinence, however the other deficits persisted through the treatment period [173] Summary of factors influencing role function and association with cognition. The research in both adult and adolescent fields describes a complex picture of the impact of mental health diagnoses and symptomology, premorbid functioning and sociodemographic factors on functional and clinical presentation and outcomes. The difficulty with clarifying factors influencing cognitive and functional outcomes is the inevitable overlap between these factors that individually may have been associated with these outcomes and the lack of knowledge about the potential accumulatory effect. For example, substance use impacts on psychological wellbeing and has an association with cognitive functioning [60, 86]; psychotic like experiences impact on psychological wellbeing but it is not yet known if PLEs are associated with cognitive functioning [122]. PLEs, however, are associated with substance use, particularly marijuana, if use commenced prior to 15 years of age [176, 177] but this does not necessarily mean that PLEs will be associated with impaired cognitive functioning. Nor does it mean that if PLEs prove to be associated with reduced cognitive functioning in the absence of substance use, the presence of PLEs and substance use combined will accentuate cognitive deficits. Given the impact of PLEs on psychological wellbeing and increased risk of mental illness, the association of PLEs on neurocognitive and role functioning requires examination. Recommendations for this research in the literature suggest ensuring socio-economic and parental education levels are controlled for [122]. 34

55 Work examining adolescent and young adult functional and quality of life outcomes has focussed on psychosis, with minimal research into the impact of other psychological states such as diagnosed mood disorders or levels of psychological distress on short to long term social and occupational functioning [20]. It has been proposed for individuals who meet the criteria for being at ultra-high risk but do not transition to psychosis, that functioning is a more stable indication of outcome than other symptoms [28]. Mental disorders such as anxiety, mood and conduct disorders are significant predictors of educational failure at both secondary and higher education level [31]. Research in the field of treatment for depression has been stunted by the focus on remission being based on achieving a cut-off score on clinical rating scales of symptoms rather than real life changes for individuals [25]. Depressed adults have indicated significant interpersonal and work deficits as well as reduced quality of life, though resolution of these deficits in line with resolution of symptoms has also not been adequately addressed [25]. Although symptomatic recovery or relief is a key treatment goal in early intervention services for all illnesses [178], measures of the impact of the illness and/or its treatment on a person s quality of life and real world functioning, and interventions specifically aimed at improving function, may be more important and motivating to affected young people, families and clinicians [179]. Future studies in adolescent and young adults experiencing depression need to target cognitive dysfunction with immediate, medium and longer term functional status incorporated as a primary outcome [25]. Research also needs to encompass both major depressive disorders and sub-threshold depressive symptomatology, as both have been identified as adversely affecting function and quality of life in both adolescent and adult populations [29, 180]. 35

56 2.7 Measuring function Lacking in a number of studies is clear developmentally appropriate functional outcomes. Researchers tend to use very general health and functioning scales that assume a homogenous developmental trajectory. It is highly possible that a person, particularly in adolescence and young adulthood, may be able to feel successful in one area of their life due to contextual and environmental supports, but not in other areas [25], and global outcome measures could mask true functional success or impairments. There are a number of useful tools measuring specific components of function validated with populations with a specific diagnostic profile such as early episode psychosis [208]. However, measuring outcomes in primary youth mental health services where diagnosis may not be afforded or apparent is a significant challenge [ ]. Outcome measures have to be suitable not only for data collection and evaluation purposes but they also must be sensitive enough to identify clinically and socially relevant change [15]. On an individual level, the process of outcome measurement must be meaningful and motivating for the young person, guiding development of individual programmes of treatment for participants rather than administrative [26]. In the field of child and adolescent assessment, minimal attention has been given to assessment tools and methods in the context of clinical work [184]. Consequently, there is a paucity of suitable assessment tools which incorporate the criteria required by therapists to provide meaningful and useable information [184]. Measuring change in the youth mental health sector is particularly difficult as young people may make progress through intervention and/or maturation, yet standardised tests frequently used by health services are often not sensitive enough to detect these changes [26]. There is a growing need to assess deterioration as well as improvement, as rates of deterioration may exceed 20% in some settings [185]. 36

57 Meaningful improvement in social and health outcomes for young people is the ultimate goal for youth early intervention services [53]. Effective collaborative goal setting is a strategy that may focus individual service provision on functional outcomes and a tool mental health professionals regularly use when working in mental health [186] [45]. In traditional mental health services, goal setting is integral to supporting recovery by providing opportunities for individualisation of outcomes [44]. Goal setting evidence consistently reports that specific, challenging goals lead to greater effort and persistence than vague or easy goals [46]. Although goal setting is common practice in delivering psychological therapies to youth [186], the influence of goal setting on motivation and clinical outcomes within this population has not been well established. Preliminary data examining the Goal Based Outcome tool in child and youth mental health services in the UK have reported that change in scores were more strongly associated with change in clinicianrated functioning and consumer satisfaction than change in psychosocial difficulties and impact on daily life, as measured by the Strengths and Difficulties Questionnaire [187]. There are a number of tools to support goal setting and facilitate a client-centred approach such as the Goal Attainment Scaling [48] and the Canadian Occupational Performance Measure [188]. However, the feasibly of these tools in the process of goal setting among younger populations requires further investigation [189]. In particular, there is an urgent need for improved evaluation of the perceived relevance, acceptability, reliability, validity and specificity of outcome measures used in mental health [190]. There is little research on the perceptions of the measures by service users, including the extent that current measures are acceptable, client-centred and meaningful [190]. 37

58 To conclude, treating functional difficulties in young people has primarily focussed on treating the suspected underlying pathology causing these difficulties. Feedback from youth and the evidence of burden of disability with mental illness suggest the need for development and evaluation of treatments focussed on improving functional outcomes to be used co-currently with standard treatment [87]. Possibly, a combination approach might yield greater client satisfaction and service engagement. Interventions focused on resilience and skill development, tend to have greater success than those focused on risk-reduction [191]. A recovery group programme in an Australian early intervention mental health service reported reasons for referrals were primarily functionally driven, with the top three reasons being issues relating to relationships and communication, time use and vocation/education [192]. The authors of this paper strongly recommend evaluation of the functional impact of youth programmes, including the evaluation of personal change goals [192]. 2.8 Conclusion and future research Adolescence to adulthood is a transition period for everyone. Change in social and occupational expectations and experimentation coupled with rapid neurobiological development increase vulnerability for distress and mental illness. Mental health services in some countries have undergone reform in the last ten years that has resulted in the development of 'no wrong door' early intervention services targeting year olds. This population is diverse in both the level of psychiatric need and functional ability, and represents a unique cohort of young people who have overcome possibly the biggest hurdle in mental health recovery, seeking help. Understanding the complex reasons why young people seek help is an emerging field of research. Specifically, the functional concerns of 38

59 young people need to be clarified to ensure that the outcome measures used, and the services provided, are adequately capturing and addressing these needs. There has been considerable research on the neurocognitive deficits in early onset psychosis and the prodromal period, and the impact these have on daily functioning. Although neurocognitive deficits have been identified in other psychological disorders and experiences, there has been less emphasis on understanding the mediating role this might play on functional outcomes. Thus, clarity around the presence and role of neurocognitive deficits in young people with broader psychological experiences is warranted and necessary to inform relevant and appropriate service provision. Research with this focus might assist in clarifying the potential impact of these experiences on developmental trajectories and improve understanding of when these experiences impact on real world outcomes and therefore potentially require early intervention. In summary, there is a general consensus that the impact of certain psychological experiences in youth may impact on neurocognitive capacity at least in the short term but could also have longer term functional consequences. A greater understanding of the association between these experiences, cognitive functioning and the functional concerns of the help-seeking youth population is needed. This will assist in ascertaining the need for intervention targeting cognitive deficits such as cognitive remediation therapy that has generated interest within the early intervention community. Research exploring role functioning and client-indentified outcomes may improve the focus of intervention and ultimately improve the evaluation processes. This will support the primary focus of youth early intervention services to improve real world, meaningful outcomes for young people. 39

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61 Chapter 3: Methods 3.1 Introduction This chapter will provide a brief summary of the salient features of the methods used in this thesis and provide greater detail of the materials that were unable to be reported in the manuscripts due to editor preferences and word count constraint. The methodological processes for each study have been described in the manuscripts presented in Chapters 4-9. This thesis comprises three discrete yet interrelated research studies, using a mixed methods research design. The use of both qualitative and quantitative research methods allowed exploration of the research problem through the direct personal experiences of young people seeking help for psychological issues, followed by an expansion of the scope of enquiry by using quantitative methods to explore different predictors of help-seeking, goal setting and role function [193, 194]. The variation in research design between studies was sequential, with the first study, reported in Chapter 4 and 8, using qualitative research methods and subsequent studies using quantitative methods. This design allowed the researcher to develop an understanding and appreciation for the experiences of the young people attending the service and afforded a greater sensitivity to the complexities of reasons for help-seeking and difficulties with role function. 3.2 Setting and participants All three studies were conducted at outer metropolitan headspace centres in South-East Queensland. headspace is the National Youth Mental Health Foundation funded by the Australian Government. It provides early intervention services for year olds, with the majority of services provided being mental health related [73]. Cognitive Behaviour Therapy 41

62 is the most frequently provided service focus [195]. As of March 2016, headspace reports 93 centres throughout Australia [196]. Participation in study one was available to all clients of headspace at one centre only. Study two and three included participants from two headspace centres. Study three constrained participation to the year old age group to capture the group of young help-seekers most at risk of vocational role disengagement. For both study one and three, flyers were placed around the waiting rooms requesting participation. Reception staff and intake staff had copies of the Participant information and Consent forms (Appendix 5) if anyone requested further information. For the recruitment and data collection period the thesis candidate was on-site 2 days/week at each centre (total 4 days/week) to answer any questions regarding participation and if possible conduct data collection on the day of enquiry. All interviews and neurocognitive testing occurred in a private office space, designated for clinical sessions. 3.3 Procedure The procedures for the three studies, including ethical considerations, have been outlined in detail in their respective manuscripts. 3.4 Ethical approval Ethical approval for all three studies was granted by the Queensland University of Technology Human Research Ethics Committee (HREC). Study one used a qualitative research design reported in Chapters 4 and 8, ethical approval number Studies 42

63 two and three both used quantitative study designs reported in Chapters 5-7 and 9, ethical approval number (Appendix A1.1). 3.5 Materials Study one used semi-structured interviewing to explore functional concerns and reasons for seeking help from the youth health organisation (Aim 1a, Chapter 4) (Appendix A2.1 and A2.2). To address Aim 1b, young people were asked to complete formal goal setting for one goal using the Goal Attainment Scaling tool (Figure 8.2, Chapter 8). Participants then completed a short semi-structured interview exploring the acceptability and value of using this tool. Goal Attainment Scaling has been used in a number of setting including community mental health [197], paediatric rehabilitation [26] and youth welfare institutions [198]. Goal Attainment Scaling has reported good inter-rater reliability, between r= [199, 200]. However, due to the idiosyncratic nature of the measure, low to moderate validity has been reported depending on the setting [199]. It is noteworthy that there have been concerns about the underlying mathematical constructs used to transform the raw GAS scores to T-scores and the subsequent evaluation of clinically meaningful change [201]. These concerns were not relevant for this study, as the Goal Attainment Scaling was used to explore client perspectives of formal goal setting practices and not for the purpose of evaluating intervention effectiveness. However, future researchers considering using the Goal Attainment Scaling should determine the psychometric properties in youth early intervention services before using this tool to measure outcomes Study two used a chart audit to collect reasons for help-seeking, service engagement, goals set and participant demographic, clinical and vocational information 43

64 from participant's initial assessment and intake information (Appendix A3.1). The data collection process is presented in Chapter 5, 6 and 9. The Kessler Psychological Distress Scale (Kessler 10 or K10) [202] is part of the minimum data set for headspace services [195] (Appendix A4.2). This measure is routinely collected for every client unless they decline, and therefore was included as a measure of distress in both studies two and three. The Kessler 10 is a ten-item questionnaire that has been used in Australian and international population surveys [60, 203]. Australia uses a 1-5 scale for each question, whereas the US and other countries use a 0-4 scale. The Australian Kessler 10 score is calculated by summing the responses to each of the ten questions to provide a total score (between 10 and 50) that is indicative of the degree of psychological distress. A total score between 10 and 15 indicates little or no distress, moderate, high and very high psychological distress [60]. Although some concern exists about the usefulness of the scale in clinical settings [203], studies have consistently found Kessler 10 scores higher in those with mental disorders [204]. Scores over 19 may indicate the presence of mental illness within the past year, whereas people with scores 19 and under are likely to be mentally well [205]. Recent Australian normative data have added validity to the use of the Kessler 10 in predicting the likelihood (79.6%, SE=3.6) of previous 12 month prevalence of serious mental disorder for those with scores in the very high range [206] Study three is a prospective cross-sectional design which utilised a range of selfreport, interview rated and clinical measures to address the research aims (Aim 2b). All the measures are reported in Manuscript 4 (Chapter 7). This section will provide greater detail about some of the measures and materials used. 44

65 Socio-demographic information, including age, gender, level of educational attainment and parental occupation were collected using self-report (Appendix A4.1). The main parental earner's occupation was scored on the Australian Socioeconomic Index 2006 to the unit group level [207] by the interviewer Vocational functioning The level and quality of participation in employment, education or in carer roles was assessed using clinical interview. Participants identified they were either 1). Not working or studying. No volunteer work or home care responsibilities, 2).Working part-time or studying part-time or have part-time home care responsibilities (caring for children or loved ones), or 3). Full-time ( 30 hours/week) working, studying and/or home care responsibilities (Appendix A4.5). The quality of role performance in education, employment or as a home maker was assessed with the Global Functioning: Role (GFR) scale [98] (Appendix A4.4). This is an interviewer-rated ten-point Likert scale where 1 = severe dysfunction and 10 = superior functioning, with detailed anchor points for each level, aimed to increase reliability [98, 208]. This tool takes into consideration age and phase of illness, and has been developed especially to measure performance in primary role (school, work or homemaker) with young people [30]. This tool was developed to capture subtle changes in role functioning symptomatic with young people suspected of experiencing prodromal difficulties as it provides three levels of functioning; current, lowest in the preceding year, and highest in the last year [98]. Inter-rater reliability has been reported well above the considered 45

66 excellent level of 0.75, with all three levels of functioning rating between 0.84 and 0.96 [98]. Preliminary evidence for construct validity demonstrated significant correlation with the Strauss-Carpenter Outcome Scale: Work/School Functioning r=0.57; and the Premorbid Adjustment Scale r=0.68 for participants and r=0.58 for parents [98]. The GFR scale is based on the demands of the vocational role, the level of support provided to the individual and the person's overall performance as a result Neurocognitive performance Participants completed six subtests from the computerised Cambridge Neuropsychological Test Automated Battery (CANTAB) [209]. CANTAB is a laptop based semi-automated cognitive tool containing 22 different cognitive tests [210]. The six subtests are purported to measure sustained attention, spatial working memory, visual memory, rule acquisition and attentional set shift (behavioural flexibility), and reflection impulsivity [210]. These tests, designed to assess a range of executive functions, have been used in studies with adolescent and young adult participants [133, 144, 160, 164]. Traditional neuropsychological tests are usually administered by neuropsychologists and can be time intensive. The CANTAB provides an alternative for this study and has a number of benefits. As well as allowing administration by a trained occupational therapist (thesis candidate), it can record aspects of performance that are difficult to measure in traditional testing, such as response time, which may be valuable in prodromal studies where early detection is very important [211]. All task stimuli are nonverbal, thereby placing minimal demands on language proficiency except to understand the instructions prior to task initiation [212]. Results from the CANTAB are automatically processed and stored and can 46

67 be recalled in a customised report format displaying both raw scores and z-scores [213]. Z- scores are calculated based on comparing the participant's raw score to the mean raw score in the supplied English reference population by age and sex. Five of the six CANTAB tests have normative data available. The relationship between CANTAB scores on component tests and a number of psychiatric and developmental disorders have been extensively reported [130, 211, 214, 215]. Although the CANTAB has demonstrated validity in discriminating clinical populations from controls and in the identification of dysfunction corresponding to expected brain structure development or lesions (discriminant validity) [212, ], comparison of the CANTAB tests to traditional neuropsychological tests (criterion validity) is not well established [218, 219]. The criterion validity for four of the six subtests used in study three were examined in healthy adults and reported moderate correlations (r=-0.26 to -0.51) between the CANTAB tests and traditional tests [218]. When age and education were controlled for, the correlation between some CANTAB subtests and respective composite factors from traditional tests varied, and the authors of this study concluded that the CANTAB provided an adequate measure of underlying general cognitive construct but a less valid measure of specific constructs [218]. The test-retest reliability is not relevant due to the cross-sectional nature of this study design however test-retest coefficients for a number of CANTAB test outcome measures have been reported as ranging from 0.60 to 0.89 [220]. The CANTAB tests used in this study are described below in the order they were administered. For each test a number of variables are available. The variables of interest for this research study are also reported. The Big Circle/Little Circle is a test of basic visual 47

68 discrimination and was the first test administered to assess understanding of the verbal instructions and as a warm-up to the Intra-Extra Dimensional Set Shift, as suggested in the CANTAB protocol [210]. The variable available for this was not included in the analysis, as all participants achieved 100% in this test. All tests had a built-in process for familiarisation, usually consisting of a number of easier stages before the more complex testing stage was presented. The CANTAB took on average 45 minutes per participant. All participants were offered rest breaks, however, only one participant utilised this with a 10 minute break after the fourth test Intra-Extra Dimensional Set Shift (IED) Figure 3.1: Intra-Extra Dimensional Set Shift Four boxes are shown on the screen. In two of the boxes there are one or two patterns. One of the patterns is the 'correct' one. Through trial and error participants learn the rules to work out which pattern is correct. This task assesses rule acquisition and behavioural flexibility (attentional set shifting) and was derived from the Wisconsin Card Sort Test of frontal lobe integrity [221]. IED has nine stages and tests the participants ability to learn, then unlearn, the association between a stimulus and reward [222]. Participants will only proceed to the next stage once six consecutive correct responses have been attained. Dependent variables reported for this test are: 1. Number of stages achieved. 48

69 2. Errors incurred at the extra dimensional shift change stage Rapid Visual Information Processing (RVP) Figure 3.2: Rapid Visual Information Processing Numbers are displayed in a box on the screen one at a time. Participants must press a button on a press pad when they identify the last number in a target sequence. RVP tests sustained attention with a small working memory component, similar to the Continuous Performance Test [223]. In this test participants must respond when they identify a predetermined target sequence of numbers (3-5-7, and 4-6-8) in a white box in the centre of the computer screen. Digits 2 to 9 are displayed in the white box randomly at the rate of 100 digits per minute [130]. Total hits and total false alarms are converted by signal detection analysis to account for the risk that target detection may be confounded by impulsive responses. Dependent variables reported for this test are: 1. RVPA': Target sensitivity (accuracy). Low score indicates difficulty discriminating target from non-target stimuli (impaired sustained attention) [130, 224]. 2. RVPB': Target response bias (impulsivity). Low score indicates participants respond in a disinhibited manner (impulsive response style) [130, 224]. 49

70 Spatial Working Memory (SWM) Figure 3.3: Spatial Working Memory A number of coloured squares (boxes) are shown on the screen. Participants must find blue tokens hidden in each of the boxes and use them to fill up an empty column on the right hand side of the screen. The colour and position of the boxes used change after each trial with a maximum of 8 boxes. This task assesses working memory and strategy and is based on a self-ordered search test [225]. The participant is required to search for hidden tokens one at a time within sets of three to eight randomly positioned boxes [214, 217]. Working memory skills are utilised as the participant, while searching, must remember and mentally update information about the locations of the tokens. A strategy score is also calculated by adding the total number of times a participant began a new search with a different box to the previous search [217]. A lower strategy score indicates a more effective searching style. Dependent variables reported for this test are: 1. Between-search errors (returning to boxes where tokens have already been found during a previous search sequence) places the most demands on working memory compared to other error scores in this test [226]. 2. Strategy score (lower score indicates superior strategy use) [144, 227]. 50

71 Paired associate learning task (PAL) Figure 3.4: Paired Associate Learning Task Boxes are opened in random order and one or more boxes will contain a pattern. Participants must remember which pattern belongs in which box. This task requires participants to form visuospatial associations to remember the location of shapes hidden behind boxes as they are revealed. It is a test of both episodic and visual memory as well as spatial planning [164, 218]. The level of difficulty increases through the test until all eight boxes contain a pattern. Dependent variables reported for this test are: 1. First trial memory score. This allowed reporting of results from participants who did not complete the test because they did not complete the final task. [164] Information Sampling Task (IST) Figure 3.5: Information Sampling Task 25 grey boxes are displayed. Behind each box is one of two colours. Participants must decide which colour is in the majority and they may open as many boxes as they like. Participants win points for a correct answer. 51

72 The IST is a test of decision making and reflection impulsivity, and measures the extent of information gathering before making a decision [215, 228]. This task places minimal demands on working and visual memory as boxes remain open once pressed and there is an interval of 30 seconds between each trial to reduce impulsive adverse response [228]. There are two test conditions. In the fixed win or no cost condition there is no penalty for the number of boxes opened. In the decreasing win or cost condition the amount of points a participant is able to win decreases with the number of boxes opened, introducing a conflict between certainty and reward [228]. As with all the tests there are a number of available outcomes. Dependent variables reported for this test are: 1. Total boxes opened as a measure of reflection impulsivity. 2. Discrimination errors for both fixed and decreasing win conditions as a measure of decision making. This error identifies when a colour choice is made that is not in the majority at the time of decision making Psychological wellbeing The Kessler Psychological Distress Scale was used to measure distress. This measure has been described in detail in Section (Appendix A4.2) The Community Assessment of Psychic Experiences (CAPE) [115, 123] was used as a measure of subclinical psychotic-like experiences. The CAPE is a self-rating 42- item questionnaire. It has a 3 factor structure; 20 questions in the positive symptoms domain (delusional thinking, auditory and visual hallucinations); 14 in the negative symptom domain (motivation, poverty of thought); and 8 in the depressive symptom domain. This 52

73 study uses the 20 question positive symptom domain (CAPE-P) (Appendix A4.3). Participants rate odd or unusual experiences on a scale of 1 (never) to 4 (nearly always). The CAPE-P comprises 4 subscales; persecutory ideas, bizarre experiences, perceptual abnormalities and magical thinking [229]. The magical thinking or grandiosity domain is less predictive of distress, depression or poor functioning [ ]. The removal of the magical thinking domain improved the psychometric properties of the positive symptom scale and reduced the scale to 15 questions (CAPE-P15) [231]. The internal consistency of the CAPE-P15 is reported at α= A mental health diagnosis where available, was collected from each participant's clinical chart and confirmed by a psychiatrist or general practitioner report in a mental health care plan, referral letter or assessment. It was expected that not all participants would have a mental health diagnosis A modified version of the Youth Risk Behaviour Survey (YBRS) [232] measured substance use frequency and quantity. The seven items used focussed on lifetime and recent use (past 30 days) (Appendix A4.6). The variables of most interest, identified from the literature review were recent cannabis use and lifetime use of other drugs such as methamphetamines and ecstasy. Reliability of items related to cannabis use in the past 30 days has been reported at kappa=0.76, and life time drug use between kappa=0.57 to 0.73, dependent on the drug [232]. The reliability estimates have reported an increase in selfreported drug and alcohol use in individuals seeking-help compared to high school samples with coefficients increasing from r=0.73 to r=0.86 [233]. Validity studies of adolescent drug use self-report has asserted very low rates of response distortion (2.6%-6.3%) [233]. 53

74 However, the validity of the YBRS has yet to be established and researchers in this field have reported challenges such as the lack of 'gold standards' and objective measures for many of the questions [232]. Regardless, the Youth Risk Behaviour Survey and modified versions has been used successfully with adolescents and young adults in a large number of previous research studies [ ]. 54

75 Chapter 4: Exploring functional concerns in help-seeking youth: A qualitative study 4.1 Preamble A primary aim of this thesis was to identify the functional concerns of young people seeking psychological help. There has been considerable financial and policy investment in the development of youth mental health services in Australia (headspace) and internationally (Jigsaw, Ireland and Youth Space, England) to bolster mental health services where they have previously been weakest [53]. As well as symptom reduction, the aim of these youth services is to improve social participation. When this current study was accepted for publication there was no literature reporting the needs of the help-seeking population, however, a recent analysis of headspace national data has reported the main reason for seeking help as being difficulties with feelings [24]. The reporting of only the main reason for help-seeking potentially under-represents the range of functional issues that might be present in this cohort. The help-seeking population is an important group as it represents young people willing to engage with services. The onus is on services to ensure they are offering intervention relevant to the needs of the young people. In order to explore the full range of reasons why young people access a youth health services, in-depth interviews with young people attending a youth service were conducted. Manuscript 1 Cairns, A., Dark, F., Kavanagh, D. & McPhail, S. (2015). Exploring functional concerns in helpseeking youth: a qualitative study. Early Intervention in Psychiatry, 9(3),

76 4.2 Exploring functional concerns in help-seeking youth: a qualitative study Abstract Aim: To explore the functional concerns of help-seeking young people years of age. Method: Semi structured interviews with n=10 young people seeking help from a youth mental health clinic were conducted. Data were transcribed verbatim and analysed using content analysis. Results were verified by member checking. Results: Participants identified reasons for seeking help with the main themes being relationships, emotional management, risk-taking behaviour and difficulties with employment. There appeared to be a difference between the concerns of the older, post school age group and the younger participants. Conclusion: Young people are able to identify their functional concerns and reasons for seeking help from mental health services. Understanding the concerns of these young people provides weight to the model of youth-specific mental health services. Future work examining concerns of 12 to 25 year olds should ensure adequate representation of the older group as their needs and concerns seem to differ from those of younger participants in this study. Post-school age youth seem under-represented in existing literature in this field. However a limitation with this study is the small sample sizes once the cohort is divided by age. Future studies with a larger, more detailed examination of the needs and concerns of this population are warranted to inform service delivery advancements and clarify the difference in needs between the post school and current school attendee groups. Keywords: Youth, Mental Health, Qualitative research, Function 56

77 4.2.2 Introduction Adolescence and young adulthood is a critical developmental period where substantial neurobiological, hormonal, occupational and social changes are occurring [3, 6, 7]. The transition for many includes completing education, commencing employment and experimenting with normal adult activities such as developing intimate relationships and using alcohol [15]. These changes allow individual opportunities for personal growth and accomplishment, however they also increase the mental health vulnerability of young people with most mental illnesses emerging during this time [15]. The impact of mental illness during this period can substantially disrupt functional outcomes, particularly educational and vocational achievements, which impacts on identity formation, limiting opportunities and the establishment of adult roles [31]. In 2003, mental disorders accounted for around 50% of the total disease burden for people aged 12 to 25 years of age in Australia [1]. A large national survey conducted in 2009 described the main reasons for psychological distress and concern in year olds as family conflict, substance use and mental health issues such as coping with stress and body image [21]. This study was repeated in 2011, coping with stress and body image continued to be two of the top three issues reported, school or study problems increased as an area of concern [237]. These studies did not report if there was a difference in the concerns of the group who sought professional help as opposed to those that did not. There is currently limited evidence in scholarly literature derived directly from young people who are seeking help from professional services regarding their self-reported primary concerns or reasons for seeking help. 57

78 Engagement in professional services has typically been low with reported rates of help seeking between 10-30% of young people who score in the clinical range for mental health problems [20, 21, 57]. In Australia, there has been substantial fiscal and policy commitment and investment in promoting and supporting early intervention in mental health [18, 22, 238]. The ultimate aim of these services is to reduce the disease burden of mental disorders for young people and their families by improving access to specialised, multidisciplinary services [22]. Young people have indicated past negative help seeking experiences as a barrier for future inclination for help seeking, reporting they sought help in the past and they felt the help wasn t useful or that their problems were not taken seriously [6]. Ensuring a match between the primary concerns of young people and the services offered is important to improve the rates of help seeking. Understanding the concerns of youth seeking help will allow for evaluation of treatment approaches against service user needs and subsequent refinement of services. This process would support professionals to offer services that are validating the expectations of young people and are responsive to their developmental and psychosocial recovery needs. This investigation aims to explore the self-reported functional concerns of young people who are seeking help from youth specific mental health services Methods Design: In depth semi-structured face to face interviews with 10 participants were conducted. The interview addressed the aim by examining the current experiences of young people who are attending a youth mental health clinic. 58

79 Participants, setting and recruitment Participants were youth (n=10) seeking help from a non-government youth mental health centre (headspace). headspace provides services to youth between the ages of 12 to 25 years of age with the aim of promoting and supporting early intervention for young people through mental health, general health, vocational and substance use services [22]. Prior to the interview commencing, potential participants were provided with verbal and written information about the study. To assess the maturity and capacity of the youth to consent to participation, they were asked to explain to the researcher their understanding of what will be expected of them, where the information will go, how their privacy will be protected and who they can contact if they have concerns about the interview or the project. The organisation ethical review board gave approval to this recruitment process to ensure that young people seeking help without parental knowledge could still be represented in the sample. This investigation was approved by the Queensland University of Technology Human Research Ethics Committee and adhered to the Declaration of Helsinki. All participants provided written informed consent prior to participation in this investigation. Participation was voluntary and parental or guardian consent was not required. Procedure and semi-structured interview A flyer advertising the research was placed in the waiting room at one of the headspace clinic locations. A member of the research team was available to answer questions relating to the research, provide information about the study and collect informed consent from participants. Semi structured one-to-one interviews were conducted at the clinic at a time convenient for the participant. Recruitment of new participants ceased once data saturation occurred. Data saturation was considered to have occurred when two consecutive patient 59

80 interviews did not add any additional categories or themes to the emerging framework. Interviews were audio recorded and transcribed. Interviews lasted approximately 30 minutes. The member of the research team conducting the interviews was an occupational therapist with 10 years experience working in mental health settings. In addition to the interview recording, demographic data were also collected for each participant. These demographic variables included age, gender, mental health diagnosis (if any), referral source to headspace (if any), occupational status (schooling and employment) and living situation (co-inhabitants). During the semi-structured interview, participants were asked if they could identify areas in their life that they were having difficulty with, specific problems (functional concerns) they were experiencing and reasons for seeking help from headspace. The interviewer then asked follow up questions to elicit the nature of the impact of the functional concerns. Participants were also prompted to identify things that were going well in their life (to describe potential protective factors in their day to day life). Data analysis Demographic information was tabulated to describe the sample (Table 1). Each interview was transcribed verbatim then rechecked for accuracy by the interviewer (while listening to the recording). Interpretative Phenomenological Analysis (IPA) [239] was used to structure the research design and examine responses. This approach seeks to identify the lived experience of participants and the meanings that these experiences hold. Data was analysed by systematically identifying and grouping themes in the text [240]. Member checking was used to confirm validity of analysis [241]. Each participant was given an opportunity to 60

81 view, amend, or add additional detail to the themes from their interview via . However, no feedback was received and therefore no amendments or additions were made. The transcripts were analysed as the study progressed Results Demographics The characteristics of the 10 individual participants are detailed in Table 1; six were female. The age range was 14-25yrs old. Two (20%) participants did not live at home; despite half the participant cohort being older than 21 years of age. One participant identified as neither working nor studying, and half the group was engaged in full time study at high school. Table 4.1: Participant demographics ordered by age. Participant Age Gender Diagnosis Referral Source Occup Status Living situation 9 14 M None Friend Student F/T Parents F Depression School Student F/T Parents & Anxiety 5 14 F None Police Student F/T Parents 3 16 F Depression GP Student F/T Parents & Anxiety 2 17 M None Self Student F/T Parents Employed P/T 7 21 M None Probation officer Employed Parents P/T 1 21 M Depression Friend Unemployed Partner & friends 6 24 F PTSD Friend Employed F/T Live in carer 4 25 F Depression Public Mental Volunteer Parents Health work P/T 8 25 F None Parent Student P/T Parents GP, general practitioner; PTSD, post-traumatic stress disorder 61

82 Themes Data reached saturation by eight interviews with the final two interviews not adding any additional categories or themes to the emerging framework (Table 2). Four prominent interrelated themes were identified including: a) Relationships; b) Emotional management; c) Risk taking behaviours; d) Employment Table 4.2: The emerging framework of four overarching themes, and categories within each theme Theme 1: Relationships Family conflict being understood, trusting parents (n=5) Positive peer relationships (n=3) Negative peer relationships bullying and disengagement (n=2) Romantic relationships (n=3) Theme 2: Managing feelings and emotions Theme 3: Risk taking behaviours Theme 4: Employment Anger (n=1) Alcohol (n=2) Motivation to work (n=2) Anxiety (n=2) Unsafe partying (n=2) Finding work (n=5) Self harm (n=1) Illegal activity for thrill seeking (n=2) Keeping employment (n=2) Depression (n=4) Illicit drug use (n=2) Finances (n=3) Impact on relationships (n=4) Impact on school work (n=1) Impact on keeping employment (n=3) Poor sleep patterns (n=1) Body Image (n=1) Truancy (n=1) Impact on work, school, hobbies and legal requirements (probation) (n=2) Housing (n=2) 62

83 Relationships Six of the ten participants identified difficulties with relationships. All the participants under 21 years of age identified this issue. The main concern of five of these six participants was conflict within the family unit, mostly arising from feelings of disengagement from parents or being in conflict with them. All of the female participants under 17 years of age (n=3) reported this issue. The link between me and my mum and me and my dad has disintegrated (p10, female, age 14) I feel I can t really trust my mum on things. And so I don t really talk to her about anything that I find important because I found that it doesn t really matter to them. (p3, female, age 16) When one 14 year old female participant (p5) was asked if she feels she has skills to work through these issues she replied, No! I have no skill. Difficulties with relationships with friends presented as less of a current concern to the young people and the peer group was often described as a protective factor by the young person despite previous experience that appeared negative. 63

84 If I had stayed at my old school, I would have just ruined my life. I would have kept going on with the things that I use to do because I hung out with people that were such a bad influence on me but now that I am at a new school they are a good influence on me and stop me from doing bad things. (p10, female, age 14) Four participants identified relationship skills as the primary purpose for seeking help. Emotional management Difficulty with responding to feelings and emotions was a major theme and appeared to be a prominent factor affecting other aspects of life such as relationships, school and work. My anger gets me into a lot of fights and gets me in trouble with the police...you know I ve just got bad temper issues and it affects my relationship with my partner. She is just scared of my anger...my voice scares her and when I do get angry my whole body tenses up and she gets scared of that and I don t like scaring her. (p1, male, age 21) I get anxiety, I get shakes, nauseous, light headed, scared like I want to either run or fight. (p2, male, age 17) [If I felt more relaxed] I would be able do better academically, would be able to excel more like I wouldn t have to worry socially. (p9, male, age 14) 64

85 One participant talked about the serious consequence of difficulties managing experiences and emotions. When I was little I was bullied and teased... that impacted on me a lot and people were very racist, they would make up names with my names and tease me...i would cry then they would laugh at me. I started self harming when I was in year six. (p10, female, age 14) Risk taking behaviour Participants reported their risk taking behaviour as a reason for seeking help. These behaviours centred on alcohol use and engaging in illegal activity for thrill seeking. I want to do the right things but they seem to be pretty boring I guess. That s why I tend to break the law a little bit. (p5, female, age 14) For one 21 year old man (p7) his alcohol use was his primary concern as it impacted on his ability to participate in hobbies, maintain employment and remain out of jail. [I have difficulty] with not wanting to stop drinking...i was almost late for probation today because I went out drinking last night and I won t have the money to buy some things for my car. I bought a carton of beer on Monday and I had to buy another carton on Tuesday night cause it was going to be all gone. (p7, male, age 21) 65

86 Employment Some participants talked about difficulties with employment as a consequence of some of their other concerns such as risk taking behaviours and anger. Of the four participants whose primary reason for seeking help related to employment, three were older than 21 years of age. The descriptions of these concerns had two sub-foci; one was obtaining (any) gainful employment, the second was obtaining desired employment. Complaints included not being able to secure full-time work (rather than part-time or casual work), work in a convenient location or dissatisfaction with their current field of employment. I m applying for jobs and just not hearing back from them at all or I haven t got the experience even though I have different certificates of qualifications it doesn t really matter you have to have the experience. It s really tough...i m going out doing the training to get the qualifications but they are just not interested. (p4, female, age 25) Well I have had some part time jobs before... I ve been looking but everything has been filled. It s especially hard because I m only a junior. (p5, female, age 14) Difficulties with employment led onto a discussion around housing and finances. One 25 year old woman reported she was still living at home, not out of choice but because she couldn t afford to move without a job Discussion This study explored the primary concerns of young people who were seeking help for psychological issues. To this end, four main themes were identified which have provided 66

87 insight into the problems young people are seeking help for. Although youth-specific mental health services are targeting young people, aged years [22], findings from this study have highlighted that there may be differences between some of the concerns of the under 18 years group and the young adult (18 to 25 years) group. For example, the younger group may be primarily concerned with family conflict, whereas slightly older clients may be less concerned with this issue (despite potentially still living with their parents). On the other hand, a prominent reason for seeking help among the older participants in this study were issues related to employment, which they reported to subsequently impact their self esteem, finances, leisure and housing goals. Interpersonal relationships with peers were not a frequently reported concern with only two participants reporting this to be a problem. This is in contrast to previous research which has reported peer relationships to be a driver for help seeking [242]. Other prominent themes identified in this study were less sensitive to age. Participants of all ages included in this study reported difficulty managing and responding to feelings and emotions in a healthy way. The issues reported by these participants varied from more traditional mental health concerns such as anxiety, depression and self harm, to the impact their behaviour was having on their relationships and school work. Difficulty with emotional management was an issue for every participant and appeared to underlie many of the practical concerns raised. The impact of psychological distress was often reported by participants to manifest in risk taking behaviour. Although these themes are interrelated, risk taking behaviour was described by participants in both the context of managing uncomfortable emotions (anger, hurt, frustration) but also for the thrill of the activity itself. 67

88 Findings from this study are consistent with prior related research. A large national survey examining the issues of concern for young Australian s (11-24 years) [21] highlighted family conflict in the top four areas of concern. This 2009 survey did not report if there was a difference with this issue between age groups, and with only 2.1% of respondents being over 20 years old the views of the older group may have been masked. The results from the 2011 survey reported that concerns with family conflict decreased with age however the representation of respondents over 20 years old was not improved [237]. These surveys also identified young Australians as being concerned with mental health problems including stress and depression [21, 237] and indicated that the older cohort (20-24 years old) were more concerned about coping with stress and depression. This is in contrast to our results which indicated that difficulties with managing emotions was not age specific and could be an indication of the difference in help seeking youth versus general population. High rates of psychological distress have been reported in Australian youth [125], with girls generally reporting greater psychological distress than boys. Risk taking behaviour has been reported in previous studies as being both a concern for young people [21] and as a natural part of the process of maturation to adulthood where risk taking holds a function for the young people who participate [142]. Other studies have identified engagement in positive vocational experiences as a fundamental component in maintaining positive psychological health [243, 244]. Understanding the concerns of these young people provides weight to the model of youthspecific mental health services where access to psychological therapies including cognitive behaviour therapy is standard treatment [245]. A salient observation from this investigation 68

89 was the employment concerns of post-school age youth. Unemployment is likely to compound negative psychological and health issues and has been associated with increased substance misuse [246, 247]. Vocational support is one of the core services headspace centres are funded to deliver. This investigation would suggest a positive match between the self-identified needs of the post-school age cohort and the services offered. Strengths, limitations and future research There are several strengths and limitations of this research, as well as some important future research directions. A strength of this study was the in depth nature of the interviews that allowed detailed examination of the concerns for these help seeking young people, thus subsequently addressing the research aim. A key limitation of this investigation was the recruitment of participants from one centre in the one location. Other young people who are accessing help from different organisations may have different opinions and experiences. It is possible the prevalence of the reported difficulties (and self-awareness of participants in identifying these difficulties) is due to the help seeking nature of these participants. Other broader youth populations may not have had the self-awareness to articulate these difficulties, or may have identified other concerns in their lives. A further limitation was the self selecting nature of recruitment which may have contributed to different experiences and levels of engagement with the researcher. A larger, more detailed examination of the needs and concerns of the help seeking young adult age group (18-25 years) is warranted to inform future service delivery advancements. Future work examining concerns of 12 to 25 year olds should ensure adequate representation of the older group, or consider post-school age youth as a separate population as their needs and concerns 69

90 seemed to differ from younger participants, and post-school age youth seem underrepresented in existing literature in this field. 4.3 Commentary This study identified four main themes for seeking help from youth mental health services. Every participant reported concerns with emotional management; this is congruent with the data from national headspace data reporting difficulties with feelings as the main reason for help-seeking in 71.6% of clients [24]. In this current study however, psychological concerns often coexisted with functional issues such as employment in the older group and relationships in the younger cohort. To ascertain if the functional needs identified in this study were representative of the larger help-seeking cohort, further research was required within a larger sample of young people. This is the purpose of the next chapter. 70

91 Statement of Contribution of Co-Authors for Thesis by Published Paper The authors listed below have certified that: 1. they meet the criteria for authorship in that they have participated in the conception, execution, or interpretation, of at least that part of the publication in their field of expertise; 2. they take public responsibility for their part of the publication, except for the responsible author who accepts overall responsibility for the publication; 3. there are no other authors of the publication according to these criteria; 4. potential conflicts of interest have been disclosed to (a) granting bodies, (b) the editor or publisher of journals or other publications, and (c) the head of the responsible academic unit, and 5. they agree to the use of the publication in the student s thesis and its publication on the QUT s eprints site consistent with any limitations set by publisher requirements. In the case of this chapter: Chapter 4 - Manuscript 1. "Exploring functional concerns in help-seeking youth: a qualitative study Early Intervention in Psychiatry, 9(3), Contributor Alice Cairns QUT Verified Signature 26/12/2016 Assoc. Prof. Steven McPhail Prof David Kavanagh Dr Frances Dark Statement of contribution Study conception and experimental design, data collection and management, analyses of data, principal manuscript writing and preparation, manuscript appraisal and editing. Aided study conception and experimental design, primary support for data analyses and manuscript appraisal and editing. Aided experimental design and manuscript appraisal and editing. Aided experimental design, contributed to analyses, and contributed to manuscript appraisal and editing. Principal Supervisor Confirmation I have sighted or other correspondence from all Co-authors confirming their certifying authorship. Assoc. Prof. Steven McPhail QUT Verified Signature 29/12/16 Name Signature Date 71

92 Chapter 5: Service disengagement and presenting issues from young people seeking help: predictors and implications for practice 5.1 Preamble The previous study identified the main themes for help-seeking, and of particular interest identified an age-related differentiation between those seeking help for social reasons (younger) and vocational or work and study reasons (older). Research into the characteristics of young people who seek help from contemporary youth early intervention services is in its infancy as services themselves are a new component of the mental health service. As discussed, headspace data has reported the main reasons for help-seeking, which identified almost 72% of consumers reporting difficulties with feelings as the primary issue, relationship problems as the second most prevalent at 11.4% and problems with school and work (6%) [24]. Difficulties with school and work were reported separately from vocational issues (1%) however it was not clear what the difference was. As stated, acute psychological issues may drive a presentation to a youth health service but the functional concerns may be more representative of disability and restricted participation. To expand on the previous study and current literature a larger investigation into the issues young people present with, which allowed for multiple reasons presenting issues was necessary and this formed the basis for the next study. As well as reasons for engagement, rates of disengagement from services were also collected as there was no published data reporting this. An analysis of predictors of both presenting issues and disengagement was then completed. Based on the previous study, the research team hypothesised that being younger would be predictive of social issues whereas being older would predict vocational issues. However, a range of relevant demographic and clinical data were included in the 72

93 analyses. The data were originally analysed as a multilevel mixed effect generalised linear model as data were collected from two sites (site was included as a random effect). The generalised linear modelling was not superior to standard logistic regressions with site included as a variable. Therefore, the analysis in this study is presented as standard logistic regressions. Manuscript 2 Cairns, A., Kavanagh, D., Dark, F. & McPhail. S. (2017). Service disengagement and presenting issues from young people seeking help: predictors and implications for practice. 73

94 5.2 Service disengagement and presenting issues from young people seeking help: predictors and implications for practice Abstract Introduction: Youth mental health services have undergone significant service development. The aim of this investigation was to identify predictors of presenting issues and service disengagement in young people who undertook initial assessments at two mental health services for year olds. Method: 283 clinical charts were reviewed. Presenting issues, service disengagement, demographic, vocational and clinical data were collated and analysed using multiple logistic regressions. Results: Older groups were more likely to present with vocational issues (OR=1.20, CI 1.08, 1.35), and younger ones for social reasons (OR=0.85, CI 0.77, 0.93). Males were more likely to present with risk taking (OR=6.39, CI 2.37, 17.23), but those using drugs were less likely to report concerns with social functioning (OR=0.42, CI 0.23, 0.75). Any employment or study participation reduced presentations for vocational issues, full-time work reduced concerns with housing or life skills, while part-time work or study was associated with social issues (OR=2.37, CI 1.00, 5.60). Nineteen percent disengaged from the service after initial assessment. Part-time employment (vs. unemployment or full-time work) was the only significant predictor of reduced disengagement (OR=0.17, CI 0.04, 0.83). Conclusion: Unemployment was associated with several presenting issues. Those part-time were much less likely to disengage from services compared to those not working or studying, suggesting that interventions to enhance motivation and better address their functional priorities may be needed. 74

95 Key words: Youth, adolescence, help-seeking, service utilisation, disengagement, community mental health Introduction Substantial investment has been made in youth mental health services internationally to improve quality and access to services and minimize negative outcomes among help-seeking youth [15, 53]. The transition between adolescence and adulthood is a time of increased vulnerability to psychological distress, with many major mental illnesses having prodromal stages in adolescence [7, 15]. In Australia, mental illness accounts for approximately 50% of the total disease burden for young people [1] with 75% of all lifetime cases of mental illness presenting before 24 years of age [16]. Although there is sound understanding of the impact of severe mental illness on the developmental trajectories and functioning of young people, there is less clarity around the impact of subthreshold symptoms [1, 50]. Previous reports have highlighted the need to reduce potential barriers to psychological help-seeking for young people and understand the needs of the youth population as a whole [19, 20, 22]. Knowledge about the functional needs and concerns of help-seeking young people is growing but has mostly focussed on the primary reason for seeking help [24, 248] rather than the full range of issues a young person may experience. Analyses of large data sets have identified mental health and behavioural concerns as the main reason for young people to seek help [24, 52], and coping with stress is a major area of concern in the general youth population [21]. Other reasons for seeking help have been identified as school work and vocational issues, relationships, alcohol and drug use, and 75

96 physical and sexual health [24, 248]. Some evidence suggests help-seeking young adults (18 years and older) may have greater concern with work and study than their younger counterparts, who have reported greater concern with relationships [248]. Focussing only on the main reasons for help-seeking may mask the true extent of functional problems that often accompany mental health concerns, as attendees may have multiple reasons for helpseeking. For example, prior research has reported 1.8% of young people identified vocational reasons for accessing a youth mental health service, but demographic data from that study revealed that half of participants aged years were looking for work [24]. Higher rates of functional issues may be more reflective of the needs of these young people and understanding these issues may assist services to refine intervention and improve engagement. Very little is known about the proportion of young people who seek help from youth specific primary mental health services but do not follow through with treatment, their reasons for disengagement or if there are any common demographic or clinical features of this cohort. Research on disengagement in general mental health services is inconsistent, due to a lack of a standardised definition and measurement of disengagement [71]. Approximately 30% of people with an early episode of psychosis disengage from services within the first months of receiving treatment, and most of these disengage in the first 12 months [72]. Common predictors of young people dropping out of tertiary mental health services include negative stereotypes of mental illness, poor insight into the need for treatment, and substance abuse[71, 72]. It is unknown if similar rates and reasons for disengagement occur in primary mental health services, where young people are experiencing psychological 76

97 distress or functional concerns, but may not (yet) meet criteria for a mental health diagnosis. In summary, current literature has described the main reason for help-seeking from youthspecific primary health care services however, rates of disengagement and participant factors influencing both presenting issues and disengagement have not been reported. The aims of this investigation were to examine the full range of presenting issues, potential predictors (from demographic, clinical and vocational variables) of: (a) self-reported presenting issues, and (b) disengagement from services Method Design, participants and setting. This cross-sectional retrospective clinical chart audit included consecutive young people (n=283) who completed an initial service assessment from August - December 2013 with a youth primary health service (headspace). headspace provides services to young people (12-25 years of age), with the aim of promoting and supporting early intervention for mental health, general health, vocational and substance use issues [22] with centres located in each state of Australia. This study included data from one outer metropolitan and one large regional centre in South East Queensland. Ethical approval for this study was granted by the Queensland University of Technology (# ), and the conduct of the study adhered to the Helsinki Declaration. 77

98 Procedure Participant's initial service assessment information and service engagement history was collected from manual auditing of their chart by a member of the research team. Deidentified demographic, clinical, vocational and service engagement information was collected. Demographic data included age, gender, romantic relationship status, and service site. Service disengagement was identified as failure to attend treatment sessions postintake assessment and categorised into a dichotomous outcome. Self-reported history of mental disorder and history of illicit drug use were recorded as yes/no responses. Categories of reported mental health diagnosis were recorded for descriptive purposes. Level of psychological distress was measured using The Kessler Psychological Distress Scale (K10) [202], routinely collected before the initial assessment interview. Responses to each of the ten questions are summed to provide a total score. A K10 score of indicates little or no distress, moderate, high and very high distress [60]. The K10 is particularly useful in predicting the likelihood of previous 12- month prevalence of serious mental disorder for those with scores in the very high range (79.6%, SE=3.6) [206]. Participants were considered to have low educational attainment if they had not completed Year 12 or higher and were not currently studying. Overall vocational engagement for each participant was categorised into: 1 = not studying or working, no carer role, 2 = part-time engagement in work, study or caring, 3 = full-time engagement in work, study or caring. 78

99 The presenting issues were primarily derived from the responses given to the intake clinician's first question "Why have you come to headspace today?" (or a version of this question). The remaining assessment information was then audited for further prominent presenting issues. An issue was determined to be prominent if they reporting of the issues indicated the participant expressed a level of concern with their situation. For example, it may have been recorded that a young person was unemployed however if there was no further discussion recorded about the person being unemployed it was not included as a presenting issue. However, if it was reported that the young person was unhappy with their level of employment or if the consequences of unemployment were affecting other areas of their life it was coded as a presenting issue. The presenting issues were then grouped into categories. The categories of presenting issues included: emotional management/ psychological (symptoms of anxiety, depression, anger, disordered eating and gaming addiction), social (relationship issues), vocational (concerns with lack of or performance in work and study), risk taking (illegal activity/delinquency and alcohol or drug use and addiction), physical health (including sexual health), and housing and life skills (difficulties maintaining accommodation, financial stress). These categories are similar to a list of functional concerns reported by a previous qualitative study in the same setting [248], and national data reporting main reasons for help-seeking [24]. Analysis Logistic regression was used to examine predictors of each of the six presenting issues. The six individual categories were used as the dependent variable in separate logistic regressions. Age (in years), gender, mental health diagnosis, level of vocational engagement, psychological distress (K10 total score), low educational attainment, relationship status and 79

100 a history of drug use were independent variables. Because data were collected from two separate sites, site was also included as an independent variable (Table 5.2). To address disengagement, nine cases were excluded from the analysis, where the reason for disengagement was outside of the control of staff or participants. This included participants who were referred elsewhere (n=5), who moved (n=3) or were not Australia citizens and therefore were not eligible to access services through the primary service delivery model (n=1). A logistic regression was then used to examine the predictions (Table 3). Significance level was set at α = 0.05 and confidence intervals are reported at 95%. Analyses were performed using STATA MP (Version 13) Results Participant characteristics A total of 283 charts were audited, 13 of which did not have complete data and were excluded from subsequent analyses. There was an equal distribution of data collected between the two sites (Site 1 n=143; 53%). Participant characteristics are displayed in Table 1. Almost a quarter of the sample (n=65) had low educational attainment, with approximately half (n=118, 44%) not being engaged in full-time equivalent study, work or caring roles. A mental health diagnosis was reported by 94 participants (35%), with depression being most commonly recorded (n=52). A history of illicit drug use was reported by 46% (n=124) of the sample. K10 scores for 199 participants (75%) were classified in high or very high distress categories [60], as shown in Figure

101 Table 5.1: Participant characteristics of the sample n = 270 Variable Mean (SD) or n (%) Mean age (standard deviation) (3.2) years Male n = 109 (40%) Currently in romantic relationship n = 96 (36%) Reduced educational attainment* n = 65 (24%) Vocational engagement Not working, studying or caring Part-time Full-time Total self-reported mental health diagnosis Categories of reported diagnosis Depression Anxiety Autistic Spectrum Disorder/Asperger s Borderline personality disorder Eating disorder Attention disorders Post-traumatic stress disorder Other Those reporting multiple diagnoses n = 75 (28%) n = 43 (16%) n = 152 (56%) n = 94 (35%) n = 52 n = 19 n = 12 n = 8 n = 8 n = 7 n = 6 n = 10 n=24 Current or previous illicit drug use n = 124 (46%) K10 mean score (SD) (9.35) *Not currently studying and have not completed secondary education 81

102 Figure 5.1: Psychological distress (K10) scores (n=270) in categories of low or no (10-15), moderate (16-21) high (22-29) or very high (>30) psychological distress [60]. Frequency Low Moderate High Very High K10 banded scores Presenting issues Eighty percent (n=217) reported more than one presenting issue (Figure 5.2). Almost all (n=259; 96%) identified issues in the psychological category. Social or relationship concerns were reported by over half the sample (n=117, 55%). Notably, 117 participants (43%) reported vocational concerns, and of these, 86 (74%) were not engaged in full-time equivalent study, work or caring roles. Help with housing and life skills were reported by 46 participants (17%) and risk taking behaviour and physical health needs were both reported by 12% of the sample (n=32). 82

103 Figure 5.2: Number of presenting issues per participant (n=270). Frequency Number of reported reasons for help seeking Results of multiple logistic regressions examining factors associated with presenting issues are in Table 5.2. Older age was associated with a greater likelihood of psychological, and vocational concerns, but a lower likelihood of social issues. Psychological presenting issues were also associated with greater distress. When compared with no work or study, participants who were working or studying were less likely to cite vocational issues, and those engaged full-time work or study were also less likely to report life skills or housing concerns. In contrast, part-time workers or students were more likely to report social issues. Being male increased the likelihood of presenting for issues relating to risk taking, as did a history of drug use, although the confidence intervals were wide. However, drug users were less likely to report social concerns. Site was the only predictor of presenting for physical health issues. 83

104 Table 5.2: Summary of logistic regressions examining potential correlates of presenting issues reported by young people (n=270). Model dependent variable, LR Chi-square(X 2 ), p-value 95% confidence intervals Independent variables OR SE Lower Upper P value Age * Psychological Gender LR X 2 (10) = 24.21, p=0.007 Mental health diagnosis Part-time (versus no work/study) Full-time (versus no work/study) Kessler * Reduced educational attainment Relationship Drug use Site Age Physical health Gender LR X 2 (10) = 13.74, p=0.19 Mental health diagnosis Part-time (versus no work/study) Full-time (versus no work/study) Kessler Reduced educational attainment Relationship Drug use Site * Age <0.001** Vocational Gender LR X 2 (10) = , p<0.001 Mental health diagnosis Part-time (versus no work/study) * Full-time (versus no work/study) <0.001** Kessler Reduced educational attainment * Relationship Drug use Site Age Housing & life skills Gender LR X 2 (10) = 24.79, p=0.01 Mental health diagnosis Part-time (versus no work/study) Full-time (versus no work/study) * Kessler Reduced educational attainment Relationship Drug use Site Age ** Social Gender LR X 2 (10) = 30.39, p<0.001 Mental health diagnosis Part-time (versus no work/study) * Full-time (versus no work/study) Kessler Reduced educational attainment Relationship Drug use * Site Age Risk taking Gender <0.001** LR X 2 (10) = 60.98, p<0.001 Mental health diagnosis Part-time (versus no work/study) Full-time (versus no work/study) Kessler Reduced educational attainment Relationship Drug use <0.001** Site OR, Odds Ratio; SE, Standard Error, LR, Log likelihood ratio. *p =0.05. **p=

105 Disengagement Of the 283 participants reviewed, 55 (19%) completed an intake assessment, then disengaged from the service. As previously stated in the analysis, to examine the potential factors associated with disengagement, 9 participants unsuitable for the service were excluded. Participants who were already engaged with private mental health services or other private psychologists (n=8) were retained in the analysis, as it was unclear if they were suitable for other interventions offered. Complete data for this analysis were available for 263 participants. Level of vocational engagement was the only factor significantly associated with service disengagement. Compared against no vocational role, participants who were working or studying part-time were less likely to disengage from the service (Table 5.3). Table 5.3: Summary of the logistic regression model (LR X 2 (10) = 19.42, p=0.04) examining associations between disengagement and variables listed (n = 263). Disengagement post intake assessment OR SE 95% confidence intervals P value Lower Upper Age Male Mental health diagnosis Vocational engagement Part-time (versus none) Full-time (versus none) * 0.41 Kessler Reduced educational attainment Relationship Drug use Site *p<

106 5.2.5 Discussion A high proportion (75%) of young people reported high or very high distress at entry into the service. This figure was similar to a national study with a similar population, where 69% of young people reported K10 scores in the high or very high range [24], both results are considerably higher than 2007 data reporting 9% of 16-24yr olds in the general population with K10 scores in this range [249]. These high levels of distress potentially reflect the genuine risk of emergent mental illness, as scores in the high and very high bands are predictive of the presence of mental illness in the previous 12 months [141]. Presenting issues and associated factors Unsurprisingly, this study identified psychological concerns as the most common presenting issue, with 96% classified as reporting this reason. This result is consistent with the elevated rates of high and very high levels of distress, and is also consistent with prior research in the field that have reported reasons for help-seeking [24, 73]. There was also a significant association between psychological help-seeking and older age. Those in the younger cohort may be less adept at self-evaluation and therefore describe their presenting issues from a role-based or functional perspective. Alternatively, concerns with functional issues (such as social problems) may precede the development of psychological issues. Although the study sites in the present investigation were primary health services with multi-disciplinary clinical staff, the predominant attended service involved individual psychology sessions, or ones focused on mental health [73]. This would suggest that the most commonly provided service was consistent with the prevailing needs of the young people seeking help. The association between physical health issues and service site is likely to be a function of the availability of general practitioner services at each site or marketing techniques to local referrers. 86

107 Those engaged in full-time work or study were less likely to present with other functional issues such as social concerns, housing and life skills. This is consistent with reported concerns about safe and adequate housing in previous research with unemployed young people [78]. Overall, individuals working or studying full-time are not appearing to want support to maintain participation indicating the service need for vocational issues is primarily in the engagement phase of education or employment. However, of concern is the association between presenting for social issues and part-time work or study. Further research exploring the trajectory of those in part-time roles may help to clarify if this association is indicative of later dysfunction. Findings from the present study extend prior research in the field [24], by that individuals may seek help for multiple reasons. Less than 20% of participants in the current study reported only one prominent presenting issue. Psychological reasons commonly co-exist with functional issues for young people, such as difficulties with social relationships or work and study. Even when such issues are present, the prompt for active engagement with youth mental health services might often be more acute, involving elevated anxiety or depression symptoms or distress. Research that only reports a primary single reason for help-seeking may inadvertently under-represent the extent of functional concerns experienced by help-seeking young people. Disengagement and associated factors Young people are notoriously difficult to engage in professional mental health services, and a range of reasons have been reported, including expense, long wait times, not thinking the treatment would help, and stigma [6, 21, 36]. In the current sample, 19% of participants 87

108 disengaged from the service after the intake assessment. Disengagement may not always be a negative outcome, and brief engagement in assessments may provide sufficient information and support, along with any natural recovery over time, for a resolution of their problems. However, the results did not indicate a relationship between lower psychological distress and disengagement which may have pointed to this possibility. The analysis of disengagement and potential correlates was exploratory and the results reflect this. It is important to note that, to our knowledge, this is the first published data relating to disengagement rates in young people accessing the contemporary youth mental health services. Regardless, the finding that young people who were engaged in part-time employment or education were much less likely to disengage compared to those who were not studying or working was interesting. We speculate that the determinants of complete disengagement from a vocational role may also carry over to disengagement from treatment services. Those in part-time roles are demonstrating a level of motivation and/or capacity to engage which may be restricted in those unemployed and not in education. On the other hand, full-time work or study did not give superior retention to no employment or study, suggesting that disengagement from treatment may have had different determinants in the full-time group: For example, they may have been difficult fitting counselling sessions within a full-time work or study schedule, or those who were successfully engaged in fulltime work may have perceived themselves as more able to solve personal issues and as having less need for ongoing support. It is also important to consider findings from the present study in light of prior research about young people who are not engaged in employment or education, which shows that 88

109 they are particularly vulnerable to mental illness and poorer longer term vocational, social and health related outcomes [ ]. Innovative methods to engage this group might be warranted, since their functional capacity may be lower than those who have obtained work or entry to training, and their management of commitments with different organisations (welfare services, job seeking agencies, etc.) may constitute barriers to the use of a health service. Once engaged with youth services, clinically significant improvements in social and occupational functioning (clinician rated) have been reported in 37% of participants with similar characteristics to those in this study [195]. However, positive employment or study outcomes in young people accessing help from contemporary youth-specific health services have not previously been reported, and remain a priority for service research. Implications for clinical practice Understanding the full extent of issues affecting young people assists services and individual clinicians to examine the full provision of care and determination of successful outcomes. In short, ensuring functional issues such as relationship or employment skills are not overshadowed by acute psychological presentations. Identifying predictors of individual presenting issues could provide support for targeted interventions. For example, greater attention to young people who are presenting with social and relationship issues may be warranted as they appear to be already disengaging from work or study and assertive intervention may prevent further withdrawal from vocational participation. By the time young people are requesting help for vocational issues, they are already more likely to have disengaged from work or study and not completed secondary schooling, further limiting opportunities. The preliminary result identifying part-timers as less likely to disengage compared to those not working or studying should be of further interest to services and 89

110 researchers. The part-time cohort may be particularly willing or have the capacity to engage in ongoing therapy, which hopefully would produce better long term outcomes for these young people. However, further research is required to ascertain these outcomes and explore if the outcomes differ depending on level of function on entry to the service. It is possible factors such as global dysfunction of individuals or the perceived lack of appropriate services offered may impact on service engagement rates of those not working or studying. Limitations This is cross-sectional data from a clinical chart audit and as such it was not possible to verify the accuracy of self-reported and clinician-recorded data or to draw causal relationships from the analyses. While the inclusion of two centres in different metropolitan geographical locations was a strength of the study, our findings may not be representative of services that are provided in other contexts. The sample size of the current study did not allow an examination of whether specific reasons for service use predicted disengagement. That clearly, is an important focus for future research Conclusion Young people reported multiple presenting issues when attending youth-specific services. Understandably, psychological reasons were most common, but most respondents also reported other concerns, often involving work, education or social issues. While youthspecific services appear to appropriately target the perceived needs of potential users, further research should investigate their relative effectiveness in addressing each of the specific presenting issues, and examine ways to improve engagement. In particular, the 90

111 association between service disengagement and lack of work and study participation compared to those who are part-time is of concern, especially since that group may have increased vulnerability to longer term functional issues. 5.3 Commentary This study confirmed that almost all young people presenting to youth services report psychological difficulties, however, they also report higher rates of vocational and social issues than previously reported. Specifically, previous data reporting main reasons for helpseeking report only 7% of young people seeking help for school, work or vocational issues whereas when allowing more than one reason to be included, presenting with concerns in their vocational role was reported by 43% of participants. Particularly concerning were the high rates of vocational disadvantage and the correlation between not in work or study (compared to part-time) and service disengagement. Data were also collected on reasons for service disengagement. This was not reported in the manuscript as clinician recorded reasons provided very little insight into motivations for disengagement (Table 5.4). Specifically, a quarter of young people were unable to be contacted to determine any reason for disengagement. For some young people who disengaged, it is possible that motivation to attend services for the initial assessment was driven by external factors for example, parents or school counsellors. Future studies assessing commitment and motivation for attendance may provide insight into likelihood of future attendance. Future research could also consider strategies to improve motivation for those most ambivalent or negative towards ongoing help-seeking. 91

112 Table 5.4: Staff reported reasons for disengagement (n=283). Attended initial assessment session only (n= 55). Reason for disengagement Did not attend follow up sessions, unable to be contacted Did not want to attend/engage Did not organise MHCP Already engaged with private mental health or psychology services Not suitable for headspace, referred to other services Moved Born overseas (not eligible for Medicare) Total number (% of those who disengaged) 14 (25%) 14 (25%) 10 (18%) 8 (15%) 5 (9%) 3 (5%) 1 (2%) Note: One reason per individual was reported. MHCP, Mental Health Care Plan. Developed by a general practitioner and allows referral to private mental health services and promotes ongoing monitoring of a person's mental health care. Finally, the data collected during this study allowed an examination of potential predictors of the levels vocational participation (not working/studying, part-time and full-time). This may provide evidence to support the development or refinement of interventions targeting young people most vulnerable to vocational role dysfunction. This analysis is the purpose of the next chapter. 92

113 Statement of Contribution of Co-Authors for Thesis by Published Paper The authors listed below have certified that: 1. they meet the criteria for authorship in that they have participated in the conception, execution, or interpretation, of at least that part of the publication in their field of expertise; 2. they take public responsibility for their part of the publication, except for the responsible author who accepts overall responsibility for the publication; 3. there are no other authors of the publication according to these criteria; 4. potential conflicts of interest have been disclosed to (a) granting bodies, (b) the editor or publisher of journals or other publications, and (c) the head of the responsible academic unit, and 5. they agree to the use of the publication in the student s thesis and its publication on the QUT s eprints site consistent with any limitations set by publisher requirements. In the case of this chapter: Chapter 5 - Manuscript 2. "Service disengagement and presenting issues from young people seeking help: predictors and implications for practice In submission" Contributor Alice Cairns QUT Verified Signature 26/12/2016 Assoc. Prof. Steven McPhail Prof David Kavanagh Dr Frances Dark Statement of contribution Study conception and experimental design, data collection and management, analyses of data, principal manuscript writing and preparation, manuscript appraisal and editing. Aided study conception and experimental design, primary support for data analyses and manuscript appraisal and editing. Aided experimental design, contributed to analyses and manuscript appraisal and editing. Aided experimental design, contributed to manuscript appraisal and editing. Principal Supervisor Confirmation I have sighted or other correspondence from all Co-authors confirming their certifying authorship. Assoc. Prof. Steven McPhail QUT Verified Signature 29/12/16 Name Signature Date 93

114 Chapter 6: Vocational engagement and underutilisation in youth primary mental health services 6.1 Preamble Chapter 5 identified that 44% of young people in the sample were either not involved in work or study or underutilised (part-time). Not working or studying, compared to part-time involvement, was also significantly associated with disengagement from youth services (OR 0.17, CI 95% 0.04, 0.83) which may suggest evidence of more global dysfunction or a mismatch between clients needs and services offered. Regardless, further examination of vocational participation rates and potential predictors was required as disengagement from work and study for extended periods of time is both detrimental for the individuals and society as a whole [75, 76]. Young people experiencing high rates of psychological distress and symptoms of mental illness appear at greater risk of exclusion [80]. Up to half of young adults seeking help from early intervention services are also looking for work [73]. Previous studies have identified rates and correlates of not being in employment, education or training (NEET) in the help-seeking cohort such as being male, being older, cannabis use and established mental illness [32]. The differences between NEET, part-time or full-time vocational participation rates and correlates have not been examined in help-seeking young people. Undoubtedly, extended periods of unemployment is damaging for many young people [76, 78]. However, work which does not offer enough hours (underutilisation) also has significant adverse effects on life satisfaction, wage rates and earning potential [253]. Part-time work or study for young people whose family commitments are often at their lowest seems, at least in the short term, a gross underutilisation of potential labour resources. 94

115 The data collected in the previous study allows an extension of the current evidence by examining potential predictors of both NEET status and part-time participation. This might provide valuable insight into characteristics of individuals most at risk of vocational disadvantage and subsequently provide evidence for interventions targeting these potential risk factors. In brief, the study reported in this chapter aimed to identify the level of vocational participation including underutilisation and predictors of these levels. Manuscript 3 Cairns, A., Kavanagh, D., Dark, F. & McPhail. S. (2017). Comparing predictors of part-time and no vocational engagement in youth primary mental health services: A brief report. Early Intervention in Psychiatry, in press. 95

116 6.2 Comparing predictors of part-time and no vocational engagement in youth primary mental health services: A brief report Abstract Aim: This investigation aims to identify if correlates of not working or studying were also correlated with part-time vocational participation. Methods: Demographic and vocational engagement information was collected from 226 participant clinical charts aged accessing a primary youth health clinic. Multinomial logistic regressions were used to examine potential correlates no and part-time vocational engagement compared to those full-time. Results: A total of 33% were not working or studying and 19% were part-time. Not working or studying was associated with secondary school drop-out and a history of drug use. These associations were not observed in those participating part-time. Conclusions: This result suggests that the markers of disadvantage observed in those not working or studying do not carry over to those who are part-time. Potentially, those who are part-time are less vulnerable to longer term disadvantage compared to their unemployed counterparts as they don't share the same indicators of disadvantage. Keywords: Youth, help-seeking, employment, education, NEET, underutilised. 96

117 6.2.2 Introduction Young people are more vulnerable to instability in the labour market [74], and those with mental illness or disability may be particularly disenfranchised when faced with challenging economic circumstances [80]. Young people accessing early intervention mental health services have reported unemployment rates of 29% in the post school age group [24] compared with 15% of young people (20-24 years) in the general population [81]. These rates are of significant concern as negative experiences of young people who are entering the workforce can influence their longer-term social, economic and behaviour outcomes [76]; with delayed engagement impacting not only on future career outcomes, but also on mental wellbeing and social prosperity [75, 79]. However, employment is not the sole indicator of vocational success in young people. Varying levels of educational engagement and the adequacy of employment combine to give a more realistic picture of vocational participation [82, 83]. Underutilisation of young people in the labour market is discussed almost solely in terms of employment, with those in part-time education or work often not being reported [84]. Underemployment more specifically refers to those who are working part-time and would like more hours [33]. Australian data in 2014 reported the underemployment rate for youth was 16.3%, twice that of all ages [33]. The non-linear flow of young people from education to employment (and for some back to education) or a combination of study and employment is the reality of contemporary youth labour markets [83]. Very little is known about the rates if young people who are studying part-time and the subsequent potential impact any participation restriction (work or study) has on mental well being, or employment and social outcomes. So, while previous research has indicated that young 97

118 people who are seeking help for psychological problems are experiencing high unemployment, the extent of their underutilisation in employment and education is unclear. Understanding factors associated with different levels of vocational engagement appropriate to young people may support more targeted intervention for vulnerable youth experiencing underutilisation. A range of factors such as level of educational attainment, gender, and substance use have been associated with NEET in help-seeking young people [32], however it is unknown if these factors are also present in those participating in work or study in a part-time capacity only. Consequently, this investigation aims to identify if correlates of not working or studying were also correlated with part-time vocational participation Methods Design and participants This retrospective cross-sectional investigation included 226 young people aged years, who accessed the community youth health service, headspace, and completed an initial assessment. Although headspace provide support from as young as 12 years of age, participants in this study were restricted to years to align with current research in this field and mandated school age laws. Two headspace centres participated, one outer metropolitan and one large regional city in South East Queensland. Ethical approval was granted by the Queensland University of Technology (approval number ). 98

119 Procedure De-identified data were collected from consecutive clinical charts by a member of the research team from August to December Initial intake and assessment information was reviewed and data collected on the participants age, gender, self-reported history of mental health diagnosis, level of psychological distress, self-reported history of any illicit drug use, amount of time spent working, studying or in a caring role, and if a participant had dropped out of secondary schooling.. Participants were considered to have dropped out of secondary schooling if they had not completed Year 12 and were not currently studying. Distress was assessed using the self-reported Kessler Psychological Distress Scale (Kessler 10) [202] at intake. During routine initial assessment, all young people were asked questions by the intake clinician regarding their employment, educational and carer role status. Levels of vocational participation were derived by the research team by combining each individual participant s reported employment status and amount of unpaid caring work and educational status to determine whether they were: 1 Not employed or studying, and not in a carer role; 2 Employed, studying or caring part time (< 30 hours/week); 3 Employed, studying or caring full time ( 30 hours/week). To ensure consistency across participants, 30 hours/week was considered full-time as this is the total number of hours a high school student is expected to attend. 99

120 Analysis Descriptive statistics were used to summarise participant characteristics. A multivariable multinominal logistic regression was used to compare correlates of not working, studying or in carer role, and working/study part-time compared with those participating full-time from age, gender, secondary school dropout, mental health diagnosis, psychological distress and current or previous drug use (Table 6.1). All statistical tests used α =.05, and confidence intervals were reported at 95%. Analyses were used STATA MP (Version 13) Results Full data were available for 223 participants. Participant characteristics are summarised in Table 6.1. There was no significant association between the level of vocational participation and the recruitment sites (X 2 =3.3, p=0.19). Table 6.1: Participant characteristics, n=223. Participant characteristics Vocational participation level N (%) or Mean (SD) Not working/studying 73 (33%) Part time work/study 42 (19%) Full time work/study 108 (48%) Age (years) 18.8 (2.6) Male 88 (39%) Secondary school dropout 64 (29%) Mental health diagnosis 83 (37%) Distress (Kessler 10) 29.4 (9) History illicit drug use 112 (50%) Site (53%) SD = standard deviation 100

121 Correlates of part-time and no vocational engagement When included in a multivariable regression (Table 6.2) a history of drug use and not completing the final year of secondary school were significantly associated with not working or studying. These variables were not correlated with those engaged part-time. Mental health diagnosis, distress and gender were not associated with either level of vocational engagement compared to those participating full-time. Table 6.2: Summary of the multinominal logistic regression (LR X 2 (12) = 97.8, p<0.001) n=223, examining associations between level of vocational engagement (compared to full time) and age, secondary school dropout, mental health (MH) diagnosis, K10 (Kessler distress scale) and history of drug use. Level of vocational engagement 1 = not working, studying or in carer role. Independent Variables Coefficient Standard Error 95% confidence intervals P value Lower Upper Age Male Secondary dropout <0.001* MH diagnosis K Drug use <0.01* 2 = part time Age Male Secondary dropout MH diagnosis K Drug use *indicates significant at p = Discussion This current study, unlike prior studies on similar samples (3, 9), included part-time vocational engagement as a measure of restricted vocational functioning. It also included unpaid carer roles as meaningful vocational engagement to reduce the risk of gender bias (since females more often assume these responsibilities). In the current sample, 33% of participants were not working, studying or in a carer role, which is 14% higher than a

122 sample from a help seeking cohort from a different location [32]. The general youth unemployment rates for the areas in which the two data collection sites belong were 14.6% (site 1) and 12.7% (site 2) in the same time period [254], considerably lower than the 33% reported by this sample. This study also included 19% who were engaged in part-time work or study only and therefore may be considered underutilised in the labour market. Not completing high school education and a history of drug use were significant correlates of not working or studying. However these correlates were not observed in those restricting their participation to part-time. This suggests that these markers of disadvantage observed in unemployed young people do not carry over to those who are part-time. It is highly possible therefore, that those who are part-time are less vulnerable to long term unemployment compared to their unemployed counterparts as they don't share the same indicators of disadvantage. There is a weight of research affirming the importance of educational attainment, particularly secondary education, in employment outcomes and subsequent work-life earnings [255, 256], and the impact of educational attainment during times of economic instability [256]. Relationships between drug use and unemployment have been repeatedly reported with both young people with mental health issues [32] and in the general population [257]. This current study utilised file data that did not differentiate infrequent occasional recreational use vs. more frequent or problematic use. However, despite this limited differentiation of drug involvement, an association with no vocational engagement still emerged. 102

123 In the current study, gender was not associated with the level of vocational engagement. This is in contrast with previous reports from similar populations which concluded males were at greater risk of not being in employment, education or training [32]. Reasons for this inconsistency are unclear, although it may be related to a greater incidence of vocational disengagement in the current study compared with prior research or the greater proportion of females (61%) compared with males (39%) included in this study. A diagnosis of a mental disorder and levels of distress were also not associated with work or study participation levels. The former result is contrary to prior research [32] and may reflect the disruption that is especially related to more severe mental health related symptoms which were not able to be accurately gleaned from the chart audit. Limitations The study relied on file-data on a cross-sectional sample, and is therefore limited by both the nature of the assessments, and by an inability to verify the accuracy of the recorded data. Consequently there are a number of other factors which may also impact on vocational engagement which were unable to be ascertained. While the inclusion of some binary variables (e.g. in relation to drug use) prevented a nuanced examination, it may also have made them less vulnerable to interpretation biases (e.g. on whether the drug use was problematic). Since the study focused on young people who were accessing communitybased early intervention services, our findings may not be representative of young people with more severe and established mental illness or greater social disadvantage. 103

124 6.2.6 Conclusion Partial or total disengagement from work and study affected half of this help-seeking sample of young people, which was substantially higher than the general youth population. The association between not working or studying, drug use and not completing secondary school were not observed in those engaged part-time. This indicates that the observed global disadvantage resulting in reduced functioning is restrained to those who are already experiencing total vocational disengagement. Services may have the greatest potential for impact on vocational participation, by developing assertive early intervention strategies tailored to improving educational attainment for vulnerable young people in senior high school to prevent dropout and ongoing substance use. 6.3 Commentary As young people leave the structured environment of secondary schooling there will inevitably be a time of exploration of work and study experiences. Although exploration is normal, this sample is experiencing particularly high rates of disengagement compared with the general population, potentially increasing longer term social and vocational disadvantage. Although the correlates in this study were useful, one of the limitations was use of data drawn from a chart audit. Chart file data limits the usefulness of the conclusions being drawn as it does not allow for validation of the variables nor identify other potential factors, not routinely collected during clinical assessment, which may influence vocational participation. Chapter 7 will explore the vocational functioning in young people further through a prospective research design with the year old age group. This age group was identified in Chapter 5 as being more likely to seek help for work and study concerns, as 104

125 well as being at greater risk of both NEET status and underutilisation, than those within the structured secondary school environment. 105

126 Statement of Contribution of Co-Authors for Thesis by Published Paper The authors listed below have certified that: 1. they meet the criteria for authorship in that they have participated in the conception, execution, or interpretation, of at least that part of the publication in their field of expertise; 2. they take public responsibility for their part of the publication, except for the responsible author who accepts overall responsibility for the publication; 3. there are no other authors of the publication according to these criteria; 4. potential conflicts of interest have been disclosed to (a) granting bodies, (b) the editor or publisher of journals or other publications, and (c) the head of the responsible academic unit, and 5. they agree to the use of the publication in the student s thesis and its publication on the QUT s eprints site consistent with any limitations set by publisher requirements. In the case of this chapter: Chapter 6 - Manuscript 3. "Comparing predictors of part-time and no vocational engagement in youth primary mental health services: A brief report Early Intervention in Psychiatry, in press." Contributor Alice Cairns QUT Verified Signature 26/12/2016 Assoc. Prof. Steven McPhail Prof David Kavanagh Dr Frances Dark Statement of contribution Study conception and experimental design, data collection and management, analyses of data, principal manuscript writing and preparation, manuscript appraisal and editing. Aided study conception and experimental design, primary support for data analyses and manuscript appraisal and editing. Aided experimental design, contributed to analyses and manuscript appraisal and editing. Aided experimental design, contributed to manuscript appraisal and editing. Principal Supervisor Confirmation I have sighted or other correspondence from all Co-authors confirming their certifying authorship. Assoc. Prof. Steven McPhail QUT Verified Signature 29/12/16 Name Signature Date 106

127 Chapter 7: Prediction of vocational participation and global role functioning in help-seeking young adults, from neurocognitive, demographic and clinical variables. 7.1 Preamble Employment has been reported as the number one goal of young people accessing early psychosis services [258], and although the prevailing issues in the youth population are psychological [24, 52], there are underlying rates of unemployment or underutilisation which are higher than the general youth population. Normal transition from secondary schooling to employment is characterised by exploration of further education and employment opportunities [2]. However, sustained unemployment and disengagement from study or training is more indicative of disability and dysfunction that may require attention [76, 79]. There has been considerable research on the neurocognitive deficits in early onset psychosis, the prodromal period and the impact these have on daily functioning [30, 99, 100, 103]. Although neurocognitive deficits have been identified in other psychological disorders and experiences, there has been less emphasis on understanding the mediating role this might play on functional outcomes [129, 130]. Thus clarity around the presence of neurocognitive deficits in young people and the impact of vocational participation is warranted in order to inform relevant and appropriate service provision. This following study aimed to identify the impact neurocognitive function had on employment and educational functioning when controlling for other relevant demographic and clinical variables. 107

128 Manuscript 4 Cairns, A., Dark, F., Kavanagh, D. & McPhail, S. (2017). Prediction of vocational participation and global role functioning in help-seeking young adults, from neurocognitive, demographic and clinical variables. Under review in a peer-reviewed journal. 108

129 7.2 Prediction of vocational participation and global role functioning in help-seeking young adults, from neurocognitive, demographic and clinical variables Abstract Background: The purpose of this study was to investigate describe neurocognitive, demographic and clinical correlates of vocational participation among a sample of young help-seeking adults. Methods: Young people (18-25 years) accessing an early intervention youth health service participated. The Global Functioning: Role scale and level of vocational participation, participant characteristics (age, gender, socioeconomic background and family history of serious mental illness), distress, psychotic-like experiences, substance use, and mental health diagnoses were recorded. The Cambridge Neuropsychological Testing Automated Battery was used to assess sustained attention, visual memory and executive function. Results: Of the 107 participants, 33 (31%) were not working or studying and 52 (49%) had a diagnosis of affective disorder. Impairments in neurocognitive tests were evidenced in attention shift, sustained attention target sensitivity, impulsivity and spatial working memory errors. Univariate analyses indicated that information processing and target impulsivity were associated with both vocational participation and global functioning, and that spatial working memory strategy was also associated with vocational participation. After controlling for significant demographic and clinical predictors, spatial working memory strategy remained a significant correlate of vocational participation (coefficient (95%CI) = (-0.17, -0.01), but no neurocognitive measures remained significant in the multivariate prediction of global functioning. 109

130 Limitations: Neurocognitive outcomes were assessed at a single time point, factors such as fluctuations in motivation could impact on test results. Conclusions: Interventions targeting work and education participation should consider the capacity of vulnerable young people to develop appropriate plans for role success and provide support accordingly. The study also emphasised the importance of high school completion and avoidance of cannabis use, especially in males. Keywords Neurocognition, CANTAB, early intervention, vocational functioning, psychiatry, youth Introduction Young people explore educational and employment opportunities as they transition from secondary schooling and move into higher education, training or employment [2]. This time can offer great opportunities for personal growth and freedoms [8]. However, instability in employment can have a detrimental effect on income, occupational status and career satisfaction later in life, and instead of successfully exploring opportunities, vulnerable young people may be left floundering in the labour market [75]. In the United Kingdom, a third of year olds have had at least one experience of not working or studying [259]. Ongoing unemployment in young people can reduce quality of life, increase ill health and social exclusion and is associated with severe levels of disadvantage through financial strain and poverty [76-78]. Young people experiencing distress and emerging mental illnesses are particularly vulnerable to employment instability with rates of unemployment or NEET (Not in Education, Employment or Training) between 19% and 29% [24, 32], compared with 13% of year olds in the general youth population [33]. 110

131 Young adults presenting to early intervention services are predominantly experiencing affective and anxiety symptoms (37-53%), high or very high levels of distress (69%) and substantial levels of disability, with 55% of year old males and 62% of similarly aged females reporting at least one day away from their occupational role due to mental ill health [24, 34]. People with severe mental illnesses such as psychosis, which emerge in adolescence and early adulthood, have been reported to have particularly high rates of unemployment, exceeding 40% [92]. Individual, regional and economic factors all impact on youth unemployment rates and disengagement from occupational role [76]. Individually, young people are at higher risk of disengagement if they are male, have a history of criminality, use cannabis or other illicit substances and experience higher rates of depressive symptoms [32, 159]. Other mental health risk factors such as psychotic-like experiences and distress have also been associated with greater disability, including unemployment [ ]. Employment outcomes have also been associated with neurocognitive functioning. For example, a meta-analysis in 2003 identified a significant association between employment status and eight neurocognitive domains, including executive function and working memory[43]. Unfortunately, the majority of the studies reviewed in the analysis did not control for important factors such as age or level of education, and the patient population was both diverse in age and diagnosis [43]. In young people, neurocognitive deficits in sustained attention and executive function including spatial working memory have been observed in depressive disorders [130, 263, 264], substance abuse issues [265, 266] and those at risk of psychosis [267]. There is a paucity of evidence investigating the impact of 111

132 these neurocognitive deficits on employment and educational engagement, and to our knowledge there are no studies assessing neurocognitive impairments in mild or subthreshold disorders in a youth help-seeking population. Accordingly, this study aimed to identify correlates of employment and education functioning from neurocognitive domains, before and after controlling for demographic and clinical factors, in a sample of young adults seeking psychological help Methods Design, participants and setting This cross-sectional, prospective investigation recruited participants between May and November All young adults aged years who sought help from two centres offering a youth health service (headspace) were invited to participate. Both centres were in South East Queensland, Australia. headspace provides early intervention services to year olds experiencing mental health, general health, vocational and substance use issues [22, 268]. This study recruited people over 18 years of age as this represents the age at which people often transition from the structured secondary school environment into either further education or employment. Due to the nature of participation, those unable to communicate in written or spoken English or with a diagnosed intellectual impairment were not eligible to participate. Approval was granted by the Queensland University of Technology Human Ethics committee (# ). 112

133 Measures Vocational functioning Participants reported their total level of vocational participation as either: 1. Not working or studying. No volunteer work or home care responsibilities, 2.Working part time or studying part time or have part time home care responsibilities (caring for children or loved ones), 3. Full time working, studying and/or home care responsibilities. The quality of role performance in education, employment or as a home maker was assessed with the Global Functioning: Role (GFR) scale [98]. This is an interviewer-rated 10-point Likert scale, from 1, severe dysfunction, to 10, superior functioning [208]. The GFR scale is based on the demands of the vocational role, the level of support provided to the individual and the person s overall performance as a result. Neurocognitive function Five neurocognitive subtests were administered from the computerised Cambridge Neuropsychological Testing Automated Battery (CANTAB) [209] measuring aspects of executive function, including decision making, visual and working memory, attention and cognitive flexibility. These tests were selected as they reportedly assess a range of neurocognitive skills and have been used previously in studies with adolescence and young adults [144, 216, 226, 227, ]. The CANTAB subtests used in this present study, their task demands and the variables of interest are displayed in Table 7.1. The Intra-extra Dimensional Set Shifting (IED) task presents participants with two patterns and through trial and error participants select the correct pattern by learning the required rule. Shifts in attention and new rule acquisition are 113

134 required in stages 8 & 9 of the task. The variable recorded was the number of errors made after extra dimensional shifts. The Rapid Visual Information Processing (RVP) task displays numbers in quick succession. The participant must watch for three target sequences (3-5-7, & 4-6-8) and press a button when they identify the last number of each sequence. Total hits and total false alarms are converted by signal detection analysis to account for the risk that target detection may be confounded by impulsive responses. The Spatial Working Memory (SWM) task requires participants to find a token that has been hidden in boxes displayed on the screen. The participant then starts searching again, until they find the number of tokens corresponding to the number of boxes that are presented at that stage. This requires participants to formulate a strategy to remember which spatial locations (boxes) previously had a token. Errors include returning to a box where they had already found a token, or to a box they already found to be empty. A strategy score is calculated by adding the total number of times a participant began a new search with a different box to the previous search. This is based on the concept that most efficient strategy is one where the participant begins each search with the same box, while a lower strategy score indicates a more effective searching style [217]. Paired Associates Learning (PAL) requires participants to form visuospatial associations to remember the location of shapes hidden behind boxes. The first trial memory score is the number of patterns correctly located after the first presentation, summed across the stages completed. The Information Sampling Task (IST) displays 25 grey boxes on the screen. Behind each box is one of two colours, and participants must decide which colour is in the majority. They may open as many boxes as they wish. There are two conditions: the no-cost condition is where participants win or lose 100 points regardless of the number of boxes opened, whereas the cost condition decreases the total number of points won from 250 points by 10 with every box opened, but an 114

135 incorrect decision loses 100 points regardless of number of boxes opened. The performance indices reported were total boxes opened and discrimination errors for both cost conditions. A discrimination error is when a colour choice is made which was not in the majority at the time of decision making (summed across the 10 trials). 115

136 Table 7.1: CANTAB subtests Task Name Task demands Task variables Intra-extra dimensional set shifting (IED) Rule acquisition and attentional set 1. EDS errors shifting Rapid visual information processing task (RVP) Sustained visual attention 1. Target sensitivity (RVPA ) 2. Response bias or impulsivity (RVPB ) Spatial working memory (SWM) Working memory and strategy 1. Total errors 2. Strategy score (lower is better) Paired associates learning (PAL) New learning and visual memory 1. First trial memory score Information Sampling Task (IST) Information processing and reflection impulsivity 1. Mean number of boxes opened per trial (No Cost and Cost) 2. Discrimination errors (No Cost and Cost) Target sensitivity RVPA (range 0.00 to 1.00); low score indicates difficulty discriminating target and therefore a sustained attention deficit. Target response RVPB (range to +1.00); low score indicates disinhibited response to non-targets suggested greater impulsivity [130]. 116

137 Socio-demographic variables Participants age (in years), gender, completion of secondary school and immediate family history of treated schizophrenia or bipolar were assessed using self-report. Participants reported the main parental earner s lifetime occupation, which and this was scored from on the Australian Socioeconomic Index 2006 (AUSE106) to the unit group level [207], in order to give a measure of socioeconomic background. Eight participants reported their parents had a long-term history of unemployment, and were unable to provide details of their parent s educational attainment. These participants were allocated 1 on this measure. Clinical variables Psychological wellbeing was assessed using self-report to give a measure of distress, psychotic-like experiences and substance use. Mental health diagnosis was collected from the participant s clinical chart and confirmed by psychiatrist or general practitioner report where available. The Kessler Psychological Distress Scale (Kessler 10) [202] measured distress experienced in the preceding month, with higher scores indicating higher levels of distress [60]. Recent (previous 30 day) cannabis and lifetime illicit other drug use such as ecstasy and methamphetamines was assessed from the Youth Risk Behaviour Survey [232], and condensed into a dichotomous yes/no response in each case. The 15-item version of the Community Assessment of Psychic Experiences positive symptom domain (CAPE-P15; [231] was used to assess subclinical psychotic-like experiences. Respondents rate odd or unusual experiences on a scale of 1 (never) to 4 (nearly always). The original 20-item CAPE-P [115, 123] comprises 4 subscales; persecutory ideas, bizarre experiences, perceptual abnormalities and magical thinking [229]. The magical thinking or 117

138 grandiosity domain is less predictive of distress, depression or poor functioning [ ]. The removal of the magical thinking domain has improved the internal reliability of the positive symptom scale, and the resultant CAPE-P15; [231] was therefore used in the current study. Procedure Individuals expressing interest were provided with information about the nature and aims of the study and expectations for participation by a member of the research team. Participants provided written informed consent and then attended a test session. During the session, participants completed demographic and clinical self-report measures, undertook a brief structured interview where employment and education role functioning were assessed, and then completed the computerised neurocognitive battery. Sessions typically lasted between 60 and 90 minutes. Statistical Analysis Descriptive statistics were used to describe the sample and outcome measures. Neurocognitive data were converted to z-scores based on the age-correlated normative data provided by the CANTAB test output. Normative data were only available for the Intraextra Dimensional Set Shifting, Rapid Visual Information Processing, Spatial Working Memory and Paired Associates Learning tasks. One-sample t-tests were used to test for differences between the participants performances and the mean normative performance (z-score = 0). 118

139 Univariate ordinal logistic regressions were performed with neurocognitive, demographic and clinical variables as independent variables and functional outcomes (GFR and vocational participation) as dependent variables to guide variable selection for the multivariable analyses. All independent variables significantly correlated (at p < 0.05) with either measure of function during univariate analyses were included in separate multivariate hierarchical ordinal logistic regressions that examined neurocognitive correlates of GFR and vocational participation, controlling for relevant demographic and clinical variables. Site was included as a random effect. The variance inflation factor (VIF) was used as an indicator of the potential impact of multicollinearity (VIF < 5 considered acceptable). Interactions between family history of schizophrenia or bipolar disorder, socioeconomic background, secondary school completion, CAPE-P15, recent cannabis use and the significant neurocognitive tests were considered by entering them (separately) into the multivariable models. However, they were inconsequential and no significant effect was observed, and therefore the models without interaction terms have been reported. Statistical analyses were performed using STATA 13 (Statcorp, Texas Version 13) Results Participant characteristics A total of 107 young people participated in the study. Demographic characteristics, vocational and clinical outcomes are reported in Table 7.2. There was a similar proportion of participants between the two sites (Site 1 n = 57, 53%). Approximately one third of the sample (n = 33, 31%) were not engaged in any work or study and approximately half (n = 52, 49%) were working or studying full time. A mental health diagnosis was reported in 75 participants (70%), affective disorders being the most common (n = 52). Forty-eight 119

140 participants (45%) reported distress in the very high range on the Kessler 10 (total score 30+) [206]. Table 7.2: Vocational, demographic and clinical characteristics of the sample. Vocational Functioning N (%) Median (IQR; range) Vocational engagement Not working/studying Part time work/study Full time work/study 33 (31%) 22 (21%) 52 (49%) Global Functioning: Role (GFR) 8 (2; 4-9) Demographic and clinical characteristics N (%) Mean (SD; range) Age (years) 20.2 (1.9;18-25) Male 41 (38%) Socioeconomic background (AUSE106) 48.7 (27.4; 1-94) Completed secondary education (Grade 12) 82 (77%) Mental health diagnosis 75 (70%) Family history of schizophrenia/bipolar 27 (25%) Distress (Kessler 10) 27.6 (7.3; 12-43) CAPE P (6.8; 16-45) Cannabis use (previous 30 days) 26 (24%) Other illicit drug use (lifetime) 44 (41%) SD = standard deviation, IQR Interquartile range, AUSE101 = Australian Socioeconomic Index 2006, Kessler 10 = Kessler psychological distress scale, CAPE P15 = Community assessment of psychic experiences 15 question positive symptom domain. Neurocognitive test performances The results of the neurocognitive variables are displayed in Table7.3, including raw scores, z- scores and t-test comparison values relative to normative data. Despite 73% of participants completing all 9 stages of the IED task, this sample performed below average on the number of errors in stage 8 & 9 (EDS errors) which requires attentional shift and rule acquisition. They also performed below average in both outcome measures of the sustained visual attention task (RVP) and total errors in the spatial working memory task (SWM). The mean 120

141 strategy score for SWM and the first trial memory score on the visual memory task (PAL) did not differ significantly from mean normative data. Table 7.3: Raw and z-scores for the individual neurocognitive tests. CANTAB subtests Raw score Mean (SD) z-score Mean (SD) t-test, p-value IED EDS errors (10.63) (1.61) -4.75, p < RVP Target sensitivity (A ) Response bias or impulsivity (B ) 0.89 (0.06) 0.90 (0.18) (1.36) (2.56) -5.21, p < , p < 0.01 SWM Total errors Strategy score (9.7) (5.22) (0.08) 0.07 (1.02) -2.04, p = , p = 0.46 PAL First trial memory score (2.84) 0.14 (0.79) 1.81, p = 0.07 IST Mean # boxes opened/trial - No Cost - Cost (5.69) 9.09 (3.66) n/a n/a Discrimination errors - No Cost - Cost 0.67 (0.93) 1.01 (1.12) IED Intra-extra dimensional set shifting, RVP = Rapid visual information processing, SWM = Spatial working memory, PAL = Paired associates learning, IST = Information Sampling Task Associations between demographic, clinical and neurocognitive variables of functioning Results from the univariate modelling are displayed in Table 7.4. Significant correlates from the univariable analyses were entered into multivariable models (Table 7.5). Errors in decision making (discrimination errors) on the information sampling task (IST) cost and nocost condition was significantly associated with decreased scores on the Global Functioning: Role (GFR) scale (Cost: coefficient = -0.39, p = 0.01; No Cost: coefficient = -0.45, p = 0.02) and reduced vocational engagement (Cost: coefficient = -0.41, p = 0.02; No Cost: coefficient = -0.47, p = 0.03). A lower and therefore more efficient strategy score in the spatial working memory task (SWM) was associated with greater vocational participation (coefficient = , p = 0.02). Reduced impulsivity on the rapid visual processing task was associated with higher scores on the GFR scale (coefficient = 2.70, p = 0.05). No other neurocognitive outcome measures were significantly associated with functioning scores. 121

142 Table 7.4: Results from univariate ordinal logistic regressions examining potential correlates of vocational functioning (n = 107). Vocational Engagement (FT, PT, None) Global Functioning: Role scale Confidence intervals Confidence intervals Coefficient SE Lower Higher Coefficient SE Lower Higher Age Male -1.06** ** Mental health diagnosis Family history schizophrenia or bipolar disorder -0.83* ** Socioeconomic status 0.02** ** Kessler CAPE - P * Completed secondary school 1.94** ** Cannabis use (previous 30days) -1.16** * Other illicit drug use (lifetime) Neurocognitive variables Intra Extra Dimensional EDS Errors Rapid visual processing - target sensitivity (A') Rapid visual processing - impulsivity (B') * Spatial working memory, total errors Spatial working memory strategy -0.08* Paired Associate Learning first trial memory score IST Mean # of boxes opened/trial - Cost condition No Cost IST discrimination errors - Cost condition -0.41* * No-cost condition -0.47* * SE, Standard Error; CAPE-P15, Community Assessment of Psychic Experiences - Positive Symptom 15 Questions; IST, Information Sampling Task. * denotes significance at p < 0.05, **denotes significance at p <

143 When significant demographic and clinical variables were introduced to the hierarchical multivariable models, multicollinearity between independent variables was not present, with all variance inflation factors below 1.4, and the mean variance inflation factor was 1.2. SWM strategy was the only neurocognitive outcome measure that remained significantly associated with level of vocational engagement (coefficient = -0.08, p = 0.05). Greater vocational participation was also correlated with being female (male coefficient = -1.25, p = 0.005), completing secondary school (coefficient = 1.94, p = 0.001), and not using cannabis in the previous 30 days (recent cannabis use coefficient = -1.32, p = 0.01). Higher scores on the GFR were significantly associated with being female (male coefficient = -1.06, p = 0.007), having a parent in a higher skilled occupation (coefficient = 0.02, p = 0.009), having no immediate family history of schizophrenia or bipolar (family history coefficient = -0.89, p = 0.04), and completing secondary school (coefficient = 1.22, p = 0.009). The association between GFR scores and recent cannabis use was just outside significance at (coefficient = , p = 0.06). 123

144 Table 7.5: Results from multivariable hierarchical ordinal logistic regressions examining potential correlates of vocational functioning, n = 107. Vocational Engagement (FT, PT, None) Global Functioning: Role scaleǂ Confidence intervals Confidence intervals Coefficient SE Lower Higher Coefficient SE Lower Higher Male -1.27** ** Family history schizophrenia or bipolar disorder * Socioeconomic status ** CAPE - P Completed secondary school 1.94** ** Cannabis use (previous 30days) -1.32* Spatial working memory strategy -0.08* Rapid visual processing - impulsivity IST discrimination errors - Cost condition No-cost condition SE, Standard Error; CAPE-P15, Community Assessment of Psychic Experiences - Positive Symptom 15 Questions; IST, Information Sampling Task. * p < 0.05, **p < 0.01 Voca onal engagement, mul variable model gave Wald X 2 (10) = 32.35, p < Akaike Information Criterion = ǂGlobal Functioning:Role scale, multivariable model gave Wald X 2 (10) = 42.22, p < Akaike Information Criterion =

145 7.2.5 Discussion This current sample of young adults seeking help from a youth mental health service performed below average on several of the executive function neurocognitive tests, including rule acquisition and shift in attention, sustained attention and response impulsivity. Normative data are not available for the information sampling task; however, the amount of information sampled (boxes opened) was comparable to previous studies of healthy young adults with both the cost and no-cost conditions of the task [265, 272]. Vocational functioning, neurocognitive outcomes and associated factors Rates of vocational disengagement (31%) in this sample were double the rate of national youth unemployment (15%) in year olds [81], although the rates of disengagement from work and study were similar to other young help-seeking samples (24-29%) [24, 34]. Impaired decision making, impulsivity and working memory strategy formation were all associated with either quality or level of vocational engagement. However, once other relevant risk factors were controlled for, strategy formation was the only significant neurocognitive correlate of level of vocational function. It is difficult to compare these results with other studies as, to our knowledge, this is the first investigation to examine neurocognitive correlates of vocational function in youth with mild or subthreshold disorders. Reviews of cognitive impairments in depressive and anxiety disorders in young adults focus on major depressive disorder as there is a paucity of studies with dysthymia or minor depressive disorder [264], which would have provided a helpful comparison. However, executive function deficits, including attentional and working memory impairment, have been reported in young adults with major depression [263, 264] 125

146 and in a non-diagnostic specific sample of young adults with a history of childhood abuse [270]. Although the current study did not compare cognitive outcomes between abstinent participants and substance users, previous studies have reported greater reflection impulsivity and impaired decision making with the information sampling task amongst adults who are current and reformed (1-8 years) amphetamine and opiate drug users [228]. No analysis of the influence of neurocognitive outcomes on function was completed within these studies, so the impact of the reported deficits on real world outcomes is unknown. Previous research has identified psychotic-like experiences as predictive of distress, poor functioning and depression in the general young adult population [61]. The CAPE-P15 was included in this present study to detect any potential effects of psychotic-like experiences, but this variable did not significantly contribute to variation in functioning. Young people who reported an immediate family history of schizophrenia or bipolar did however, have reduced levels of vocational functioning. Studies with psychosis at-risk groups report evidence of both neurocognitive deficits and declines in functioning up to 10 years prior to clinical diagnosis [35, 41]. Cognitively, this includes reduced processing speed [30, 273], impairments in attention [267, 273] and executive function [273]. As already noted, some of these deficits were present in our sample. SWM strategy score was not impaired compared to normative samples; but it was correlated to vocational functioning. It is likely that the relationship between function and strategy formation is genuine but not specific to the help-seeking cohort. The process of formulating and executing a methodical plan to improve success, is a skill that potentially differentiates the normal variate in employment outcomes in the general population. 126

147 Demographic and clinical variables were much stronger correlates of vocational engagement and role functioning in this sample than were the neurocognitive ones. This is congruent with other studies of work and study outcomes in young people which has also identified gender, educational attainment, socioeconomic background, recent cannabis use and, as previously discussed, family history of schizophrenia or bipolar disorder [32, 90]. Prior research specific to help-seeking young people also identified being male and recent cannabis use as associated with not being in education, employment or training [32]. In particular the influence of cannabis use on functioning in young people is well reported and regardless of psychiatric status there is an association between frequent harmful use and higher emotional and behavioural problems [36], reduced educational attainment [54, 56] and vocational functioning [32, 159, 161]. Limitations Neurocognitive and clinical outcomes were assessed at a single time point, and fluctuations in attention, motivation and various other factors may therefore have impacted on test results. An assessment of outcome measures over time would be valuable to assess the stability of outcomes and potentially investigate direction of causality. A control group matched for region as well as age, gender and socioeconomic status may have provided a better estimate of the relative CANTAB performance profile of the current sample than was given by reliance on the CANTAB database and subsequent statistical control, but acquisition of such a sample lay outside the scope of this current study. Alcohol consumption was not reported and biochemical assays were not undertaken to confirm selfreports. Future studies may consider more detailed assessment of recent consumption to rule out potential influence of acute usage and withdrawal on cognitive performance [157]. 127

148 Participants were self-selected, and therefore representativeness of the help-seeking sample are unknown, but their demographic characteristics do not indicate that sampling bias was present [24]. This sample was from an early intervention community service, and many may not therefore have received a comprehensive diagnostic assessment in the past. As a result, the control for a mental disorder diagnosis may have missed any influence of undiagnosed disorder, although measures of psychological distress (Kessler 10) and psychotic-like experiences (CAPE-P15) were included in the analysis as well as diagnosis to adjust for severity of psychological distress and psychotic-like experiences, respectively. This study considers the correlation between cognitive deficits and vocational functioning in young people predominantly experiencing affective and anxiety disorders. Although most measures of cognitive capacity did not meaningfully differentiate work and study outcomes after potential confounders, the significant association between vocational participation and the capacity to plan and implement an effective strategy for task completion (as assessed by strategy score on spatial working memory task) should not be overlooked. The effectiveness of interventions aimed at improving vocational participation may be enhanced by assessment and counselling of task strategy as well as targeting behavioural change such as alcohol and drug counselling and school-based support to improve secondary school completion. 7.3 Commentary This study assessed a community sample of young adults primarily seeking help for psychological issues to determine the level of vocational participation and quality of vocational functioning. This study investigated potential correlates of functioning and paid 128

149 particular attention to neurocognitive deficits. The outcomes suggested minimal involvement of neurocognitive capacity on functional outcomes. Exogenous factors such as gender, socioeconomic background and family mental health history, and behavioural factors such as recent cannabis use and secondary school completion rates were significantly correlated with vocational functioning. There has been interest in the use of cognitive remediation therapy with young people experiencing cognitive difficulties without a psychotic disorder [ ]. This study would not support the trial of this therapy as the influence of cognition on function was minimal. There is a smattering of studies trialling this therapy with a variety of populations and presentations not involving psychosis where the focus has been on cognitive outcomes with very little mention of the durability of outcome or functional change [278]. Efforts should focus on drug counselling, particularly targeting recent cannabis use, improving secondary completion rates and vocational engagement, particularly for those considered most at risk due to gender or family background. 129

150 Statement of Contribution of Co-Authors for Thesis by Published Paper The authors listed below have certified that: 1. they meet the criteria for authorship in that they have participated in the conception, execution, or interpretation, of at least that part of the publication in their field of expertise; 2. they take public responsibility for their part of the publication, except for the responsible author who accepts overall responsibility for the publication; 3. there are no other authors of the publication according to these criteria; 4. potential conflicts of interest have been disclosed to (a) granting bodies, (b) the editor or publisher of journals or other publications, and (c) the head of the responsible academic unit, and 5. they agree to the use of the publication in the student s thesis and its publication on the QUT s eprints site consistent with any limitations set by publisher requirements. In the case of this chapter: Chapter 7 - Manuscript 4. "Prediction of vocational participation and global role functioning in helpseeking young adults, from neurocognitive, demographic and clinical variables In submission." Contributor Alice Cairns QUT Verified Signature 26/12/2016 Assoc. Prof. Steven McPhail Prof David Kavanagh Dr Frances Dark Statement of contribution Study conception and experimental design, data collection and management, analyses of data, principal manuscript writing and preparation, manuscript appraisal and editing. Aided study conception and experimental design, primary support for data analyses and manuscript appraisal and editing. Aided experimental design, contributed to analyses and manuscript appraisal and editing. Aided study conception and experimental design, contributed to manuscript appraisal and editing. Principal Supervisor Confirmation I have sighted or other correspondence from all Co-authors confirming their certifying authorship. Assoc. Prof. Steven McPhail QUT Verified Signature 29/12/16 Name Signature Date 130

151 Chapter 8: Setting measureable goals with young people: qualitative feedback from the Goal Attainment Scale in youth mental health 8.1 Preamble The previous four chapters have explored reasons and predictors of help-seeking with a focus on capturing functional concerns. This focus was then narrowed to examine the impact neurocognitive, demographic and clinical factors had on vocational participation. The next two chapters (Chapters 8 and 9) complement these studies by exploring goal setting, a commonly used clinical and service tool to engage people in self-identification of needs. Research reporting effectiveness of treatment for depression has primarily focused on remission being based on achieving a cut-off score on symptom rating scales rather than functional changes meaningful for individuals [25]. The headspace minimum data set has included the Social and Occupational Functioning Scale (SOFAS) as a measure of functioning to complement measures of psychological distress [195]. This is an admirable attempt to balance symptom based outcomes with functional measures that may yield valuable aggregate data for large scale analyses. However, the usefulness of this measure for identifying client-centred improvement may be limited [279]. The SOFAS score is clinicianrated and does not require consultation from clients. The use of this tool as the sole functional evaluation method seems at odds with the headspace philosophy of youth involvement as it does not indicate whether change on SOFAS is experienced as a meaningful, functional improvement by the young person. 131

152 Goal-based outcomes that utilise client-identified goals for therapy may be effective in identifying a focus for intervention and provide a platform for the evaluation of meaningful functional change. Goal setting is already considered best practice in mental health [44]. It requires neither the introduction of new programs nor the recruitment of specialist staff, and has been identified as having the potential to improve functional outcomes in a range of clinical and non-clinical settings [46, 47]. Goal setting has been identified in organisational, general health and specific mental health recovery literature as being a key element in motivation for change [44, 46, 47]. There are a number of tools to support effective goal setting including the Goal Attainment Scaling [190], but the feasibility and acceptability of using this tool with young people is unknown. This chapter reports data collected during the qualitative interviews reported in Chapter 4 and it explores if young people found it acceptable and valuable to use their reasons for help-seeking to set goals using a standardised format, Goal Attainment Scaling. Manuscript 5 Cairns, A., Kavanagh, D., Dark, F. & McPhail. S. (2015) Setting measureable goals with young people: qualitative feedback from the Goal Attainment Scale in youth mental health. British Journal of Occupational Therapy, 78(4),

153 8.2 Setting measureable goals with young people: qualitative feedback from the Goal Attainment Scale in youth mental health Abstract Introduction: Measuring occupational performance is an essential part of clinical practice however there is little research on service user perceptions of measures. The aim of this investigation was to explore the acceptability and utility of one occupational performance outcome measure, Goal Attainment Scaling (GAS), with young people (12-25 years old) seeking psychological help. Method: Semi-structured interviews were conducted with ten young people seeking help from a youth mental health clinic. Interviews were audio taped and a field diary kept. Interviews were transcribed verbatim and analysed using content analysis. Results were verified by member checking. Results: All participants were able to engage in using GAS to set goals for therapy, and reported the process to be useful. The participants identified the physical location and ownership of the scale was important to help motivate them to work on their goals. Conclusion: Young help-seekers see GAS as an acceptable tool to facilitate the establishment of functional goals. Young service users were particularly keen to maintain control over the physical location of completed forms. Keywords: Youth, Goal Attainment Scaling, outcome measure, mental health, qualitative research, 133

154 8.2.2 Introduction Over the past decade, there has been substantial Government financial and policy commitment to promoting and supporting early intervention in mental health [18, 22, 280, 281] and improving youth specific services to address the high levels of mental distress and subsequent poorer health and functional outcomes. The ultimate aim of these services is to reduce the disease burden of mental disorders for young people and their families, by improving access to specialised, multidisciplinary services [22]. Symptomatic recovery or relief is a key treatment goal in early intervention services [178] and is often the main outcome variable assessed [198] however, the measure of the impact of the illness (or its treatment) on a person s quality of life and real world functioning may be more important to clients, families and clinicians [179]. Measuring outcomes in youth mental health services is a significant challenge for individual clinicians, service managers and researchers [ ]. On an individual level, outcome measures must be sensitive enough to identify change relevant to the young person and the process must be meaningful and motivating to be responsive to the needs of young people [26]. Measuring change in youth mental health is particularly difficult, as young people may make progress as a result of intervention or maturation, but the range of standardised tests typically used by health services are not sufficiently sensitive enough to detect those changes [26]. General health and functioning scales used in research and clinical practice often assume a homogenous developmental trajectory. It is likely that an adolescent or young adult may be more able to function in one life domain than another, due in part to differences in their relative demands and supports for effective performance [25]. Global outcome measures could mask true functional success or impairments in different domains. 134

155 Accordingly, there is growing support for standardised questionnaires to be complemented by instruments that support strengths-based and recovery practices that embrace individual differences in areas of functioning [198]. Currently, research on goal setting in adolescence is predominately focused on sports and athletics, despite consensus that adolescence is a crucial time for the formation of personal goals and directions in a range of other areas, and the fact that these decisions potentially have important long-term implications [282]. Client-centred practice is widely accepted as key to good clinical practice [283], it has been cited as being associated with positive outcomes such as improved functional outcomes and increased client satisfaction [284]. Involving clients in the goal setting process is seen as an essential component in client-centred practice with calls for occupational therapists to develop and utilise strategies to aid this process [189, 284]. There are a number of tools to support goal setting and facilitate a client-centred approach such as the Goal Attainment Scaling [48], and the Canadian Occupational Performance Measure [188]. However the feasibly of these tools in the process of goal setting among younger populations requires further investigation [189]. In particular, there is an urgent need for improved evaluation of the perceived relevance, acceptability, reliability, validity and specificity of outcome measures used in mental health [190]. There is little research on the perceptions of the measures by service users, including the extent that current measures are acceptable, client-centred and meaningful [190]. Goal Attainment Scaling (GAS) [48], is an individualised measurement tool that is commonly used to assess occupational performance [189, 190], but has much wider potential application. GAS has been used in paediatric rehabilitation settings [26, 285] and in both 135

156 general and mental health services [197, 286]. GAS has been used in youth welfare institutions [198] but has not yet been tested in community youth mental health services. GAS assists the person to identify their own goals for treatment or training, and to break the potential degree of goal attainment into a 5-point scale, with defined criteria for each score [48]. GAS has been suggested by clinicians as being easier to use for functional problems, but more difficult to use for medical problems [287]. A recent review of the use of patient specific instruments in the process of goal setting included the GAS, however all the studies analysed were either with patients 40 years and older or patients with strokes the majority of which were likely to be in the older age group [189]. On the whole, goal setting research has often focused on the benefits to delivery of services, monitoring and evaluation, with little research about users perceptions of goal setting [190, 288]. Therefore this investigation aims to examine the perceived utility and acceptability of GAS, using qualitative methods with a sample of adolescents and young adults attending a community youth-focused mental health service Method Design: In-depth semi-structured face to face interviews with ten participants were conducted, and responses were analysed using Interpretative Phenomenological Analysis. Participants, setting and recruitment Participants were young people aged years of age, who were seeking help from a nongovernment youth mental health centre. This centre provides services exclusively to young people (12-25 years of age), with the aim of promoting and supporting early intervention for 136

157 mental health issues [22]. Anyone accessing this service was eligible to participate. Prior to the interview, potential participants were given oral and written information about the study. To assess their capacity to consent to participation in the absence of parental consent, potential participants were asked to summarise the key points in the information sheet before giving written consent. The study was completed as part of the requirements towards a research higher degree for the principal researcher and was approved by relevant human ethics committees of Queensland University of Technology approval number and adhered to the Declaration of Helsinki. Procedure and semi-structured interview A flyer advertising the research was placed in the waiting room at the clinic. The principal researcher answered questions relating to the research, provided information about the study and collected informed consent from participants. Semi-structured individual interviews were conducted in the clinic by the principal researcher who is an occupational therapist with 10 years of experience working in mental health settings. In addition to the interview recording, demographic data (age, gender, any mental health diagnosis, vocational and educational status and living situation) were collected. During the audio-recorded interview, participants were asked about their reasons for seeking help, and identified one goal they most wanted to work on. They were shown a GAS worksheet, and further articulated the goal they wanted to work toward over the next 3 months, using a SMART goal (specific, measurable, acceptable, realistic, time-related) format [285]. This goal was written on the GAS form (see Figure 8.1), and five levels of 137

158 SMART goal attainment were identified, with interviewer support. Time taken to complete the scale was later obtained from the audio recording. Participants were then asked how easy (or difficult) the GAS was to complete. Additional questions focused on the acceptability and perceived usefulness of the process and specifically of the GAS. An interview schedule is attached (Appendix A2.2), due to the reflexive nature of the qualitative interviews, this schedule is illustrative with the interviewer frequently asking follow up questions to participants to allow for more detailed exploration of participants experiences. A field diary was kept by the interviewer to record reflections after each interview about the difficulty facilitating the goal-setting process and the level of engagement of participants. Recruitment of new participants continued until data saturation occurred (i.e. where four consecutive participant interviews did not add additional categories or themes to the emerging framework). 138

159 Figure 8.1: Goal Attainment Scale (participant 10, female, 14 years) -2 Able to do much less than expected -1 Somewhat less than expected 0 Expected outcome (goal) +1 Somewhat more than expected +2 Much more than expected Goal: To have a better relationship with Dad and to be happy around him. -2 Regularly get angry at Dad, start ignoring him and storm out of the house. Not talk to him at all. -1 Small talk (5-10 mins) daily, superficial conversation. Never go out together. Occasionally get angry. 0 Talk for longer (10-15 mins), deeper conversations. Rarely get angry. +1 Feel much calmer with Dad, talk for 15-25minues at one time. Had 1 or 2 alone activities with just Dad. +2 Going out alone together, relaxed conversations. Feel able to just hang out together. 139

160 Analysis Each interview was transcribed verbatim from the audio recording and after the transcripts were checked for accuracy by the interviewer, recordings were destroyed. Interpretative Phenomenological Analysis (IPA) was used to structure the research and examine responses [239]. IPA is a method of qualitative data analysis that is concerned with individual s perceptions at a particular time rather than the development of objective accounts and is particularly suited for small samples of between five and ten participants [239, 289, 290]. IPA recognises the involvement of the researcher in the ongoing interpretation during interviews and allows for further testing of presumptions during interview phase. The field diary was used in this study to note these presumptions and ensure the researcher s own interpretations were appropriately recognised and analysed alongside the participant transcripts. Analysis was conducted by the principal researcher in the first instance with at least one other member of the research team checking to verify the themes and emerging framework at each stage of the analysis. A third member of the research team was available to arbitrate if any unresolved disagreement occurred, but was not required. Themes in the text were systematically identified and grouped [240]. Initial analysis involved reviewing a single interview transcript (participant 1) was examined and interesting or significant points were noted. This provided a base of key comments to build on with subsequent transcripts analysed for these preliminary themes as well as new themes. Copies of the transcripts were then made in a word document to allow comments to be grouped in the documents under the appropriate theme. The transcripts were then reread to ensure the themes in the document and listed comments captured the experiences conveyed by the participants. 140

161 The field diary was then reviewed against the master document, and reflections from this recording were added to emerging categories and themes. Member checking was used to confirm the validity of analysis [241]. Each participant was ed a summary of the themes derived from their interview, and was asked to make any required amendments or additions. However, no changes were suggested by them. Transcripts were analysed progressively throughout the study Results Demographics Demographic characteristics of the ten participants are in Table 8.1. They were aged between 14 and 25 years. Eight lived in the family home and five were in full time study at high school. Table 8.1: Participant demographics. Participant Diagnosis Age Gender Vocational Status Living situation 1 Depression 21 M Unemployed Partner & friends 2 None 17 M Student (full time) Parents Employed (part time) 3 Depression 16 F Student (full time) Parents & Anxiety 4 Depression 25 F Volunteer work Parents (part time) 5 None 14 F Student (full time) Parents 6 PTSD 24 F Employed (full time) Lives with a person with a disability as a carer 7 None 21 M Employed (part time) Parents 8 None 25 F Student (part time) Parents 9 None 14 M Student (full time) Parents 10 Depression & Anxiety 14 F Student (full time) Parents 141

162 Goal Attainment Scaling All participants completed a GAS worksheet on their goal. The goal themes, categories and the number of participants who identified with each theme are listed in Table 8.2. Improving social relationships was the most common goal with reducing frequency of participation in unhealthy leisure activities second. Table 8.2: Overall goal themes (related to person s role), categories and number of participants who identified with these categories. Themes Categories # Participants (n=10) Improve relationships Social 3 Romantic 1 Leisure time Increase physical activity 1 Reduce unhealthy activities 2 (drinking, law breaking) Work Improve productivity 1 School Reduce anxiety 1 Domestic activities of daily living Learn to cook 1 Three prominent themes emerged in the interview: a) Motivation b) Physical location and ownership of goals c) Collaboration of writing goals Motivation In regard to the usefulness of the GAS, all participants said they thought it was useful. Discussions particularly focused on using the tool to generate motivation. 142

163 I think this would be very useful cause it allows you to set a goal to reach...and it will allow you to track your progress...and see if you need to work harder towards it or if you are going really well (p2, male, age 17) "set s it [the goal] out plainly, it s there and there s no excuse not to follow it. (p7, male, age 21) One participant provided realistic insights into the multidimensional nature of motivation. While tools such as the GAS were seen as useful, motivation to make behaviour changes may require more than this initial goal setting. Going over this [GAS] is useful to do with anyone...but just because you write it down doesn t mean you get around to [doing] it (p3, female, age 16) Physical location and ownership of goals Four participants made direct reference to their plans for the physical location of the form. Location was related to the scale s ability to provide ongoing motivation to continue working on the goal. I can have it somewhere like in a folder with all my important stuff like, when I m going through it...i can see it and go sweet,...i ve done that and tick that off (p1, male, age 21) 143

164 I ll have to look at it every now and again and think of the outcomes [of nonachievement]...i ll probably hang it up in my room before I go out or at the door or something (p5, female, age 14) I can pin them up where I go past them every day and think I can do that goal, I can try my best and then try and achieve it. (p10, female, age 14) Seven participants reported setting therapy goals in the past, but not being able to remember them. The interrelationship between the location of goal sheets and a sense of ownership of goals was emphasised. it just sets it out...the goals you can actually see the goals and...when you talk to a counsellor they don t actually write the goals, they just write on the pads themselves you don t actually get to see it and you forget, all that stuff (p1, male, age 21) Collaboration in goal setting Although all participants reported that they felt the scale was easy to complete, three acknowledged that this was because the interviewer assisted with explanations of the different levels, and collaborated with the participant to ensure that goals were measurable. The interviewer s reflections in the field diary described this process and the clinical skill required to support participants to ensure their goals were measurable. 144

165 needed a lot of support to make sure the goal were measureable. [P10] kept changing what she wanted to measure, not the goal itself but how she would know if there was a difference (field diary, notes after interview with p10, female age 14) One of the older participants articulated the grounding nature of using a tool like the GAS in encouraging realistic goals. I don t think there was anything difficult [about completing the GAS] but I think just reality, it is all good knowing what you would like to have but writing what you think you will have is different (p4, female, age 25) Discussion This study explored the acceptability of the Goal Attainment Scaling with help-seeking young people. Feedback was overwhelmingly positive, with all participants setting one goal using the GAS scale and reporting the goal setting process to be acceptable, helpful and valued. Notes from the field diary supported the positive participant s responses to using the GAS but highlighted the importance of professional competence in guiding the goal setting process. The themes from the interviews and field diary provided insight into the collaboration required to develop SMART goals using the GAS, and emphasised the importance of the form s ownership and location. A number of participants made specific reference to where they would put the goal sheet at home, and how this would help them remain committed to work on their goal. Best practice clinical guidelines state service users should be given copies of all documents completed unless they decline (National Collaborating Centre for Mental Health, 2012). Goal engagement is widely believed to lead to higher levels of goal attainment [291]. Though goal setting theorists assert that the 145

166 primary benefit of participation is cognitive rather than motivational in that it stimulates discussion on task strategy, boosting self-efficacy [292]. The young people in this study specifically referenced the use of the scale as a strategy to remain focused on goal attainment, highlighting that goal setting using GAS is not just administration of a tool but is also considered a clinical intervention [293]. Regardless of the mechanism for improvement, tools such as GAS can encourage professionals to fulfil their requirements to participate in goal-setting from a client centred perspective and stimulate discussions with clients about strategies for goal attainment. Direct comparison of the findings from this study to prior research is difficult, given the paucity of research in this field. Previous studies of the GAS have included paediatric neurological rehabilitation [285], youth welfare institutions [198], adult rehabilitation [288], geriatric care [287] and adult mental health settings [294]. These prior studies focused primarily on the utility of GAS from the clinician and service perspective, and their findings focused on a number of process and implementation experiences and perceived impact of GAS. The only overlap with this study was the reported difficulties in ensuring clear and concise wording to describe the GAS levels for goals (Stolee, Zaza et al. 1999) which was also identified in the interview field diary. The current study appears to be the first to offer young people's perspectives on GAS. The findings from this investigation should be considered in relation to the principles that guide youth mental health services. Specifically, early intervention mental health services have been tasked with facilitating and embedding the recovery oriented practice into their 146

167 service delivery model [295], with a key principle of recovery practice involving individuals and their carers being able to control goal setting and evaluation [296]. Participants reported past experience of setting goals at in clinical sessions, but of having these goals documented by the counsellor, without a copy being given to them. Many could not remember the goals that they had set in previous meetings, and reported that these goals were not systematically reviewed. Goal setting is an essential component of many psychological therapies including cognitive- behavioural therapies [297, 298]. This has confirmed the acceptability of goal setting with young people, but also highlighted the importance of the way that information is stored and used. This sentiment has been echoed in public adult mental health services, with service users perceiving goal sheets to be owned by mental health staff as opposed to clients, impacting on motivation to complete the tasks and relevance to the person s therapy [299]. Strengths, limitations and future research A strength of this study was the use of a qualitative approach, affording detailed examination of feedback from these young people. Its main limitation was the recruitment of participants from one geographical location. Young people accessing help from other organisations may have had different opinions and experiences, although the generic applicability of the GAS approach makes this unlikely. A further limitation was the selfselected recruitment, which may have led to the sample being more able and willing to engage in goal setting than were other service users. Routine use of the approach in the service will clarify whether that was indeed the case. 147

168 Future research may consider other aspects of validity, reliability and responsiveness of the GAS among youth seeking help from mental health services [190], and should examine the process of evaluating goal attainment at later assessments. The impact of the GAS on goal attainment, and its sensitivity to change, also need further attention. It is likely participants would have been able to engage in setting more than one goal, although it is unknown if this would have changed their perspectives on the acceptability of the GAS. Further research could explore the relationship between number of goals set, likelihood of attainment, engagement in initial goal setting sessions and subsequent therapy Conclusion Young people seeking help are able to clearly identify areas of concern and in collaboration with a clinician, set specific and measureable goals for therapy using GAS. Goal setting is a process valued by this group and is often reported as an essential element in the treatment models provided by youth mental health services. This study highlighted the need for this goal setting process to be in line with recovery principles, in particular, emphasising the importance of the ownership of goals remaining with the individual. It adds to the body of evidence informing the clinical practice of occupational therapists, whose skill in task analysis can make a unique contribution to the development of service-user goals that are relevant, measurable and timely. Key Findings Goal setting using the Goal Attainment Scaling is a valued and acceptable process for young people seeking psychological help. 148

169 What this study has added This study contributes to the body of evidence validating the use of occupational performance outcome measures by exploring the experiences of a small group of service users. 8.3 Commentary This paper was the first to describe the use of the Goal Attainment Scaling with young people seeking help from a youth-specific mental health service. The participants found the process of goal setting both valuable and acceptable, with a number focusing on the use of the scale to provide ongoing motivation for goal attainment. During the course of this study, participants reported they had set goals during the initial assessment session with the service. Goal setting practices in broad youth early intervention services has not been examined, it is unknown what proportion of young people are able and willing to engage in goal setting, if setting goals improves engagement or how useful these goals might be at measuring outcomes. These questions are be the focus of the final manuscript in this thesis. 149

170 Statement of Contribution of Co-Authors for Thesis by Published Paper The authors listed below have certified that: 1. they meet the criteria for authorship in that they have participated in the conception, execution, or interpretation, of at least that part of the publication in their field of expertise; 2. they take public responsibility for their part of the publication, except for the responsible author who accepts overall responsibility for the publication; 3. there are no other authors of the publication according to these criteria; 4. potential conflicts of interest have been disclosed to (a) granting bodies, (b) the editor or publisher of journals or other publications, and (c) the head of the responsible academic unit, and 5. they agree to the use of the publication in the student s thesis and its publication on the QUT s eprints site consistent with any limitations set by publisher requirements. In the case of this chapter: Chapter 8 - Manuscript 5. "Setting measureable goals with young people: qualitative feedback from the Goal Attainment Scale in youth mental health. British Journal of Occupational Therapy, 78(4), " Contributor Alice Cairns QUT Verified Signature 26/12/2016 Assoc. Prof. Steven McPhail Prof David Kavanagh Dr Frances Dark Statement of contribution Study conception and experimental design, data collection and management, analyses of data, principal manuscript writing and preparation, manuscript appraisal and editing. Aided study conception and experimental design, primary support for data analyses and manuscript appraisal and editing. Aided experimental design and manuscript appraisal and editing. Aided experimental design, contributed to analyses, and manuscript appraisal and editing. Principal Supervisor Confirmation I have sighted or other correspondence from all Co-authors confirming their certifying authorship. Assoc. Prof. Steven McPhail _QUT Verified Signature 29/12/16 Name Signature Date 150

171 Chapter 9: Focusing on function in youth mental health: Could goal setting help engagement? 9.1 Preamble Chapter 9 describes the final analysis undertaken as a part of this doctoral program of research. The previous chapter explored the experiences of young people applying the Goal Attainment Scaling to transform reasons for help-seeking into specific and measurable goals suitable for evaluation. It identified that young people valued the goal setting process and found the use of formal tools acceptable. Goal setting is a valuable clinical tool used by many professionals working in health. It is championed by those supportive of recoveryoriented mental health service provision [44, 45] and if goals are specific, measurable and challenging, goal setting can motivate behaviour change and improve functional outcomes [46, 47]. Participants interviewed in the previous study reported setting goals during their initial assessment with headspace, however, this was a small self-selected cohort and may not be representative of the general help-seeking population. The Irish youth mental health service Jigsaw also report interventions are goal focused [52] but do not state if those goals adhere to best practice guidelines of being specific, measurable, achievable/acceptable, realistic and timed (SMART) [300]. Further investigation of the use and quality of goal setting practices in routine practice in youth mental health may provide insight into a potentially cost effective strategy for identifying client-centred outcomes and motivating behaviour change. 151

172 This final study draws on cross-sectional data collected during study 2 to determine if goals are routinely being set during the initial assessment into headspace and the quality of those goals assessed against the SMART criteria. This study also aims to explore the relationship between service engagement and goal quality to add to the information reported in Chapter 5 on predictors of service disengagement. This chapter answers the question, how SMART is goal setting in youth mental health? Manuscript 6 Cairns, A., Dark, F., Kavanagh, D. & McPhail, S. (2017). Focusing on function in youth mental health: Could goal setting help engagement? This paper is under review in a peer-reviewed journal. 152

173 9.2 Focusing on function in youth mental health: Could goal setting help engagement? Abstract Background: Effective goal setting has potential to improve client outcomes. Purpose: To identify if goal setting in youth services was specific, measurable and timed; and if goal quality predicted service engagement. Method: Clinical assessments were reviewed for 283, year-olds accessing a youth mental health service in Australia to determine if goals were being set. 166 goals from 74 participants were further analysed and assessed against specific, measurable and timed criteria. Negative binominal regression was used to identify correlates of service engagement from goal quality and demographic variables. Findings: Goal setting was evident in 187 participants (66%). Of the 166 goals analysed, 95 goals were specific, 23 measurable, 0 timed. Goal setting was correlated with increased number of therapy sessions attended, though goal quality did not provide superior engagement. Implications: Goal setting was occurring though not adhering to SMART goal setting guidelines. This potentially limits the benefits of this cost-effective tool in aiding the evaluation of individualised functional outcomes. Key words: Youth, goal setting, SMART, occupational therapy, psychiatry 153

174 9.2.2 Introduction For good reason, youth mental health services have expanded considerably in the last 10 years in a number of industrialised nations. Mental illness may account for 50% of the total disease burden in young people in a population [1] and 75% of all lifetime cases of mental illness are present before 24 years of age [16]. Services such as headspace (Australia), Jigsaw (Ireland) and Youth Space (England) have been implemented to provide community based mental health services to young people bridging the adolescent to adulthood transition. The aim of these initiatives is to strengthen the mental health service where it is weakest and improve the mental well-being and social inclusion of emerging adults through early intervention [53]. Canada is on the cusp of such transformation with the release of 'Taking the Next Step Forward: Building a Responsive Mental Health and Addiction System for Emerging Adults' [70] and the establishment of initiatives such as ACCESS Mental Health [63]. The implementation of youth mental health services and the plight of the young people they intend to service should be of interest to all health professions working within the mental health field. In the Australian and Irish context, there is evidence of high rates of distress, disability and restricted social participation already present in young people attending early intervention services [24, 32]. Half of year olds accessing headspace are looking for work and rates of NEET (not in employment, education or training) have been estimated to be between 19% and 29% among year olds [24, 32, 73]. Although there are numerous organisations providing vocational services and programs to young people, the evidence supporting any particular model is scarce. Regardless, full social participation, not just symptom relief, should be at the core of service delivery for young people [34, 301] and this 154

175 is an area occupational therapists should be championing [302, 303]. Meaningful change in social and health outcomes for young people is the aim for youth services such as headspace [245]. However, the current paucity of evidence regarding the effectiveness of youth mental health services in improving social participation has been noted and remains a priority for research and future service development [70]. Effective collaborative goal setting is a strategy that may focus service provision on functional outcomes that are important to the consumer and a tool regularly used by mental health professionals [45, 186]. In traditional mental health services, goal setting is integral to supporting recovery by providing opportunities for individualisation of outcomes [44]. Studies investigating goal setting have consistently reported that setting specific challenging goals has been associated with greater effort and persistence from goal setters in comparison to vague or easy goals [46]. In clinical practice this has been observed in cerebrovascular rehabilitation settings, where setting functional measurable goals at service entry was correlated with higher discharge scores on the Functional Independence Measure compared to patients who made general goal statements [47]; and specific, challenging goals improved immediate performance in cognitive and motor tasks [304]. Although goal setting is common practice in delivering psychological therapies to youth [186], the influence of goal setting on motivation and clinical outcomes within this population have not been well established. Preliminary data examining the Goal Based Outcome tool in child and youth mental health services in the UK, have reported change in scores were more strongly associated with change in clinician-rated functioning and consumer satisfaction than change in psychosocial difficulties and impact on daily life as measured by the Strengths and Difficulties Questionnaire [187]. Goal setting tools that facilitate functional, 155

176 specific goal statements such as the Goal Attainment Scaling, have been trialled with young people attending community youth services and found to be acceptable and valued by young people [305]. This previous study however, highlighted the importance of the role of the professional in guiding the goal setting process to ensure goals were measurable and achievable. The skill of occupational therapists in activity and task analysis and the imbuement of client-centred practices into the occupational therapy training and philosophy [306] could make a unique contribution to the process of goal setting in youth health services [305], with the aim of improving functional outcomes. The Jigsaw youth service postulates interventions are goal focussed [52]; however, they have not reported whether goals frequently adhere to best practice criteria of SMART (specific, measurable, achievable, realistic/relevant and timed) [285, 300]. This is also true with the Australian headspace service where, service users have reported goal setting [305] but the adherence to SMART criteria has not been examined. Goal setting during the headspace assessment and engagement process was the focus of the present investigation and the potential influence this initial experience with the service may have on subsequent engagement. The aim of this investigation was to: (a) explore potential correlates of goal setting practice from consumer characteristics and service data, (b) identify if goals set are specific, measurable and timed, and (c) explore if the quality of goals could predict level of engagement. 156

177 9.2.3 Methods Design, participants and procedure This cross-sectional investigation audited 283 consecutive clinical charts from young people aged years old accessing the community youth health service, headspace. This was part of larger a study examining reasons for help-seeking and vocational disengagement in this population. headspace is an Australian-wide initiative which provides services to year olds with the primary aim of promoting and supporting early intervention for mental health issues as well as general health, vocational and substance use problems (McGorry, et al., 2007). Young people seeking help from a headspace centre typically have at least one initial engagement and assessment session to determine the individual s needs. They are then referred to an appropriate headspace therapist to provide ongoing mental (or physical) health services [73]. Although occupational therapists are a small percentage of the workforce, they provide both assessment and ongoing treatment services [73]. Two headspace centres in South East Queensland, Australia participated in this study. Ethical approval was granted by the Queensland University of Technology (approval number ). Service engagement and assessment information was reviewed. Basic demographic and clinical data including age (in years), gender, current or previous drug use, presence of mental health diagnosis, disengagement from the service after the assessment session, service site, total number of therapy sessions attended (engagement) and work or study participation was collected. Engagement in work and/or study, service disengagement and history of drug use were recorded as a dichotomous yes/no response. Evidence of goal setting was also recorded as a yes/no response. A sub-sample of the first 74 consecutive 157

178 charts reviewed with a goal setting yes response were included in a further analysis of the content of the goals. The goals reported in the clinical charts were recorded verbatim. Analysis Goal content was collated into predetermined categories derived from previously reported functional concerns and reasons for help-seeking which included: Emotional management, relationship/interpersonal, vocational (school/work), living skills (eg. housing, life planning), alcohol/drug related goals and physical health [24, 248]. Sexual health goals were collated under the physical health category. An other category was included for goals that did not fit into any of the categories above. If a goal identified two categories, the goal was allocated to the category which corresponded to the intended outcome. For example, a participant s goal was to manage social anxiety to stay employed. This goal would potentially fit both in the emotional management and vocational category. However, because the participant identified the intended outcome was to remain employed this goal was allocated to the vocational category. Goals were further assessed against the SMART (specific, measurable, achievable, realistic/relevant and timed) framework for goal setting [300]. Because of the complexity and personal nature of determining if a goal is realistic or achievable, these two components were not included in the analysis. Therefore, goals were assessed by a yes/no outcome on being: 1. Specific did they define exactly what is being pursued? 2. Measurable is there a clear way to track completion? 3. Time frame is there any reference to time? 158

179 Goal quality analysis was conducted by the first author in the first instance and was reviewed by one other member of the research team for accuracy. A third member of the research team was available to arbitrate disagreements, however this was not required. To identify the potential correlation between the sum of sessions attended and goal setting quality at initial service assessment, goals were allocated a quality index score. 0=no goals recorded; 1=goals were reported but did not adhere to any SMART category; 2= at least one goal set per participant contained one SMART category; 3= at least one goal set contained two SMART categories; 4 = at least one goal set contained all three SMART categories.. For this, participants with goals recorded were included if the quality of their goals had been audited (n=74), and participants with no goal were included as the referent for comparison purposes within the model. Due to distribution of the dependent variable (sum of sessions attended), a negative binomial regression model was used to examine if total sessions attended was predicted by goal quality (independent variable) with a 0-3 ordinal scale, 0 (no goal) as the referent for comparison purposes. Univariate analysis identified potential co-variates including age, gender, vocational participation, history of drug use, mental health diagnosis and service site were analysed. Independent variables correlated with number of session attended at p<0.2 were then included in a multivariable negative binominal regression. Univariate logistic regressions were initially used to explore potential correlates of goal setting (dichotomous dependent variable) n=283, from age, gender, vocational participation, history of drug use, mental health diagnosis, service disengagement and the service site (independent variables). 9 cases were excluded from the service disengagement analysis as the reason for disengagement was outside of the control of staff or participants 159

180 such as, participants who were not suitable for the service and referred elsewhere (n=5), or people who had moved outside of the service catchment areas (n=3) or were not Australia citizens and therefore were not eligible to access services through the primary service delivery model (n=1). Independent variables correlated with goal setting at p<0.2 were then included in a multivariable logistic regression to identify variables correlated with a person s likelihood to set goals when other variables are controlled for. Data analyses were conducted using Stata MP (version 13) Results Participant characteristics and service data At least one goal was recorded for 187 participants (66%). Mean age of the sample was 18 years (SD=3.1). There were 18% more female participants than male (female=167; 59%), more than a quarter of participants were not working or studying (n=82; 29%), a mental health diagnosis was recorded for 101 (36%) participants and 129 (46%) reported current or previous drug use (46%). There were 8% more participants recruited from one of the service sites (Site 1=153; 54%) in comparison to the other site. The median (IQR) number of sessions attended excluding the intake assessment was 5 (2-10) and 55 (19%) participants disengaged from the service after the assessment session. SMART goal content and correlation with service engagement Of the 74 participants included in the sub-analysis, a total of 166 goals were analysed with 88% (n=65) of participants reporting between 1-3 goals (Figure 9.1). The frequency of goal categories is reported in Table 9.1. Goals of improving emotional management and wellbeing were the most frequently recorded with support for depression and anxiety 160

181 symptoms contributing to half of this. Goals that were included in the other category were: stay out of jail (n=1), engage with psychologist/talk to someone (n=4), be a better person (n=1), get a handle on life (n=1), be normal (n=1) and increase my mental health to increase functioning (n=1). The last goal was allocated to the other category as the authors were unable to specify what aspect of the participant s mental health needed improvement or what area of functioning was the focus. Figure 9.1: Number of goals recorded per participant (n=74) 161

182 Table 9.1: Type of goals reported by help-seeking young people. 166 goals analysed. Goal category N(%) Emotional management/feelings 107 (64%) Depression/mood symptoms 26 Anxiety 25 Self esteem 12 Stress management 11 General coping 10 Anger management 7 Suicide/self-harm 6 Eating disorder 3 Psychotic symptoms 3 Trauma counselling 2 Motivation 2 Relationship/interpersonal 20 (12%) Vocational (work/study) 11 (7%) Living skills (eg. Housing, community access) 9 (5%) Alcohol and drug 6 (4%) Physical health 3 (2%) Other 9 (5%) None of the goals analysed met the full criteria for being specific, measurable and timed. 95 goals (57%) were identified as being specific and 23 were measurable (14%). All the goals that were considered measurable were also specific. None of the goals included a timeframe. 22 of the 23 measurable goals were identified as measurable as they inferred a dichotomous yes/no measure, for example, "stop smoking cannabis" or "get a job". Results from the negative binomial regression identified any goal compared to no goal was associated with a greater number of sessions attended (Table 9.2). The multivariable regression identified no history of drug use increased the number of sessions attended but did not influence the correlation between goal quality or number of sessions attended. Goals that were specific, or specific and measurable did not give superior service engagement to setting a goal that was not specific or measureable. 162

183 Table 9.2: Results from univariate and multivariate negative binominal regressions examining potential correlates of number of sessions attended (dependent variable) n=165. Univariate Mul variable β p β p Goal qualityǂ Not specific or measureable <0.01 Specific goal not measureable 0.89 < <0.001 Specific and measurable goal <0.01 Age n/a - Male Not working or studying n/a - Mental health diagnosis n/a - History of drug use Service site Overall model LR X 2 (6) = 33.24, p<0.001 ǂ No goal is the referent comparison category Goal setting correlates The second univariate analysis identified age, drug use, service site and disengagement as correlated with setting goals at the p=0.2 threshold (Table 9.3). When entered into a multivariable logistic regression, service disengagement and site remained significant at p<0.01 (Table 9.3). Compared to the univariate analysis, there was very little change in the odds ratio, confidence interval or p-value for service site or disengagement in the multivariable analysis. 163

184 Table 9.3: Results from univariate and multivariable logistic regression examining potential correlates of goal setting (dependent variable). Univariate n=283 Multivariable n=274 OR p OR p Age Male Not working or studying Mental health diagnosis Drug use Service disengagement 0.30 < <0.001 Service site 2.06 < OR, Odds Ratio Service disengagement n=274 The overall model gave LR X 2 (4) = 25.65, p< Discussion Over two thirds of young people in this study set goals during their initial engagement and assessment sessions. Of those 74 participants included in the sub-analysis, 52 (30%) identified more than one goal. This is congruent with previous research from youth mental health services where the majority of young people report more than one reason for helpseeking [52] and young people find goal setting to be acceptable and valued [305]. SMART goals and content Of the 166 goals analysed, the majority of goals (64%) were related to improvements in emotional management. Goals related to functional outcomes such as improved relationships, work, study or life skills totalled 24%, and goal setting for physical health improvements was the least common (2%). These results are consistent with national headspace data reporting 71.6% of young people were having problems with feelings, 18.4% report help-seeking for concerns with role functioning and 6.6% for physical health issues 164

185 [24]. The Jigsaw model does not provide physical health services however presenting issues to this service are similar as issues such as anxiety and worry, anger and thoughts of hurting one s self are the most commonly reported [52]. Tangible outcomes are potentially more important to young people and their families [179] and it is likely the intended outcome for some of the emotional goals was subsequent improvement in functioning however this was not able to be assessed in this current study. In this study, the majority of goals did not adhere to the SMART goal practices. Negotiating specific, realistic and measurable goals with service users is perceived to be time consuming [300] and this may have impacted on this outcome. Almost all of the measurable goals used a dichotomous measurement and although yes/no outcomes are measurable, they do not allow for partial success and the achievability of these goals may be limited. This may inadvertently be detrimental to individuals who do not achieve a positive result [307]. Goal setting is not a one size fits all process, and although it appears setting goals, regardless of quality, is more helpful than no goals with regards to service engagement, evaluation of goal attainment was outside the scope of this research which may provide evidence for the impact of specific, measurable and realistic goals on outcomes. It is possible that more specific and measureable goal setting at service engagement may improve outcomes through more targeted interventions and/or through stimulating motivation for behaviour change as seen in other settings [46]. Effective goal setting is challenging but idiographic measures may provide an alternative evaluation tool to global assessments of functioning, more sensitive to outcomes meaningful to consumers [308]. This study did not explore the process for reviewing goals. 165

186 However, previous research reported young people could not always remember the goals they had set at entry into services and that they were not systematically reviewed [305]. The process for goal evaluation and feedback would be an important area of research as the effectiveness of goal setting with youth accessing community services is unknown. Goal setting correlates In this sample, goal setting was not significantly correlated with age, gender, presence of mental health diagnosis, history of drug use or vocational functioning. These results are encouraging as they suggest the acceptability of goal setting amongst a broad range of young people. Attending treatment sessions was correlated with goals being recorded. This result was evidenced with both the full data set that examined the presence of goals (Table 3) and goal quality (Table 2). It is possible those that disengaged from the service after the assessment session, did not set a goal as it was their intention not to return. There is very little information about disengagement from youth early intervention services comparable to headspace and the authors could find no literature discussing the influence of goal setting on this. Comprehensive school-based engagement models postulate goal setting, focused on task rather than ability, as important for school engagement but it is unknown if this would following though to health services [309, 310]. Further research exploring the motivation to attend ongoing intervention pre and post assessment may give insight into the potential mediating role of goal setting. It is possible that strengthening goal setting practices could reduce the rate of service disengagement. In this study, any goal significantly predicted an increase in the number of sessions attended although there was not a clear difference between the quality of goals and the number of sessions. It is noteworthy that 166

187 increased sessions may not necessarily be a positive outcome if the purpose of intervention is unclear. The influence of site when disengagement was controlled for, suggests a possible disparity in the implementation of routine goal setting and recording during the initial assessment between the sites. Goal setting has been found to be acceptable with young people [305] so refusal to engage in the goal setting process is unlikely to be a factor but inability to identify a goal might be. It is possible differences in staffing competencies, service culture and participant characteristics such as motivation to attend services may contribute [311, 312]. Implications for practice This study has highlighted that although most young people in our sample are setting goals when they engage with youth services, a limited number these goals are specific and measurable. Idiographic outcome measures, such as goal setting are not being used to their full potential, despite the desire from youth services to improve functional outcomes [53]. Professionals working in youth mental health services may find it beneficial to consider the purpose of goal setting for the service and the young person, and if necessary strengthen practice to afford measurement of client-desired change. The Canadian ACCESS-MH network report a focus on youths' own goals as a key activity to promote high-quality, appropriate care [63]. Canadian occupational therapists have an opportunity in this development phase to hold these services accountable to their rhetoric of individualised client-centred care by championing the use of idiographic outcome measures such as the Goal Based Outcome tool [313], the Goal Attainment Scaling [48] or the Canadian Occupational Performance Measure [188]. 167

188 Limitations Although the goals were written in a manner that was suggestive of being identified by youth, the authors were unable to validate this as data were retrospective, collected from clinical charts. This study focused on goal setting at the assessment phase of service engagement and did not examine the presence and content of goals set during ongoing therapy services. SMART goals could be routinely set by intervention staff though it is unlikely this would negate the need for specific and measurable goals for overall service provision. The process for setting goals, goal feedback and staff s perceptions on the utility of setting goals was not explored during this study and would be valuable information for service improvement. Lastly a dichotomous assessment of engagement in work or study is a basic determination of occupational functioning and does not provide any assessment of the quality of engagement or the supports an individual might be receiving. It is possible that a more detailed assessment of the quality of vocational functioning might identify a correlation between goal setting and function Conclusion This appears to be the first study to assess the rates of goal setting at youth mental health services and evaluate the content of those goals against SMART criteria. Prior evidence suggests specific and measurable goal setting at the assessment phase of service engagement should identify service user focus, improves motivation for goal achievement and stimulates discussion on strategies for attainment. This study has highlighted the majority of young people are setting goals but those goals are not always specific, rarely measurable and seem unlikely to be realistically achieved either due to the all or nothing outcome or the relatively small number of average service sessions. Occupational therapists 168

189 can make a valuable contribution in facilitating the process for evidence-based goal setting, providing an evaluation platform to measure specific, client-driven outcomes. 9.3 Commentary This study has been the first to use a large cohort of young people to describe the content and quality of goals set at entry into a contemporary youth early intervention service. This study indentified that the majority of young people appear capable and willing to set goals for treatment with goals of emotional management being the most common, contributing 63% of all goals reported. This supports the findings in Chapter 4 & 5 which identified difficulties with emotions as the main reason young people report seeking help. Unfortunately, the goal setting practices analysed in this study were not always specific and rarely measurable, impacting on the potential usefulness of this practice to either motivate behaviour change or support evaluation of goal attainment and outcomes. It is unlikely this finding was due to young people refusing to engage in this process as Chapter 8 identified that young people were willing to engage in formal goal setting practices and valued the process, considering it motivational. Future research in this field may consider exploring the use of goal setting further, both in its relationship with service engagement and effectiveness in evaluating meaningful outcomes. Strengthening already existing practice and trialling the use of regular selfevaluation and feedback may prove to be a cost effective way to improve service provision and, most importantly, facilitate meaningful outcomes for young people. 169

190 Statement of Contribution of Co-Authors for Thesis by Published Paper The authors listed below have certified that: 1. they meet the criteria for authorship in that they have participated in the conception, execution, or interpretation, of at least that part of the publication in their field of expertise; 2. they take public responsibility for their part of the publication, except for the responsible author who accepts overall responsibility for the publication; 3. there are no other authors of the publication according to these criteria; 4. potential conflicts of interest have been disclosed to (a) granting bodies, (b) the editor or publisher of journals or other publications, and (c) the head of the responsible academic unit, and 5. they agree to the use of the publication in the student s thesis and its publication on the QUT s eprints site consistent with any limitations set by publisher requirements. In the case of this chapter: Chapter 9 - Manuscript 6. "Focusing on function in youth mental health: Could goal setting help engagement? Under review in peer-reviewed journal." Contributor Alice Cairns QUT Verified Signature 26/12/2016 Assoc. Prof. Steven McPhail Prof David Kavanagh Dr Frances Dark Statement of contribution Study conception and experimental design, data collection and management, analyses of data, principal manuscript writing and preparation, manuscript appraisal and editing. Aided study conception and experimental design, primary support for data analyses and manuscript appraisal and editing. Aided experimental design, contributed to analyses and manuscript appraisal and editing. Aided study conception and experimental design, contributed to manuscript appraisal and editing. Principal Supervisor Confirmation I have sighted or other correspondence from all Co-authors confirming their certifying authorship. Assoc. Prof. Steven McPhail QUT Verified Signature 29/12/16 Name Signature Date 170

191 Chapter 10: General Discussion 10.1 Summary and Strengths This thesis demonstrated that young people seek help for a range of psychological and functional issues. Restricted vocational participation is an issue for almost half of these young people and is associated with a range of demographic and clinical variables including service disengagement. The final two manuscripts in this thesis identified that although goal setting was a common practice in initial service assessments, these goals did not adhere to best practice SMART guidelines, which potentially limited any benefits. This is despite the qualitative investigation, identifying that young people find formal goal setting to be an acceptable and valuable tool. The first study utilising qualitative semi-structured interviewing, demonstrated that although young people are help-seeking for a variety of reasons, all young people reported concerns with emotional management. However, emotional concerns most often coexisted with role-based or functional concerns. Noteworthy was the age differentiation between those years of age who were more likely to seek help for issues with work or study, whereas those under 18 years were more likely to express concerns with relationships. This study also identified young people being able and willing to transform reasons for helpseeking into functional, specific and measurable goals using a formal goal setting tool, Goal Attainment Scaling. Young people in this study identified they wanted physical ownership over goal forms and they could not recall goals that were written and kept by clinicians in clinical charts. However, locating goals in clinical charts may limit the effectiveness of the 171

192 goal setting process to motivate behaviour change and undermine the client-centred focus of the services. Study two analysed data from a retrospective consecutive chart audit of 283 young people who attended participating headspace centres. The first analysis of this data extended the findings in the qualitative study and confirmed that young people reported multiple presenting issues, with psychological needs the most commonly reported issue followed by social and vocational concerns. Understanding the full extent of issues concerning young people encourages services to remain mindful of role dysfunction, which may be overshadowed by acute psychological presentations which may prompt service engagement. This study also reported predictors of the six individual categories of presenting issues that may be important for developing targeted interventions for specific issues. For example, those seeking help for social issues were more likely to be working or studying part-time (compared to not working/studying), therefore assertive interpersonal skill building for those who are part-time may improve social outcomes and prevent further vocational disengagement. Finally, this investigation also presented the first report on rates and predictors of service disengagement in contemporary youth mental health services such as headspace. Although difficult to compare due to the paucity of research, 19% disengagement did not seem unreasonable considering the difficulty in engaging this client group in mental health services. However, of concern was the association between disengagement and not working or studying compared to those part-time and not completing secondary school. Although secondary school dropout did not meet α > 0.05 probability cut-off for statistical significance (p=0.06), with an odds ratio of 2.15 and confidence intervals that just cross 1 (0.96, 4.80), it is possible that with a slightly larger 172

193 sample this variable would be significant. Logically, this fits with the theory that disengagement from other life roles carries over to disengagement from services. The high rates of unemployment and substantial levels of underemployment or part-time vocational engagement stimulated further analysis of vocational participation.. This analysis identified that when controlling for other variables, vocational disengagement was associated with other indicators of disadvantage such as a history of drug use and secondary school dropout. This indicates a potential subgroup of young people who are experiencing behavioural and educational disadvantage, who incidentally may also be disengaging from these services at greater rates than other young people. Assertive engagement of these young people in services that target work and education engagement as well as drug and alcohol counselling may be warranted. The final analyses from the chart audit data examined goal-setting practices for a larger cohort, extending on the research from the qualitative study.. This demonstrated that goal setting is extremely common in the youth services where data were collected, with the majority of help-seekers identifying goals for ongoing intervention. Unsurprisingly, there was a correlation between disengagement from the service and not setting a goal during the initial assessment. Exploring the underlying reasons for this may provide clarity as to the intention and expectation of the young person engaging in the services with an aim to improve retention rates. This study also analysed 166 goals from 74 consecutive participant charts. Each goal was recorded, and analysed against three SMART goal criteria; specific, measureable and timed. 173

194 None of the goals met the full criteria, and only 14% were both specific and measurable. Finally, through indexing goal quality, this study identified that goal setting increased the number of service sessions attended. However, there was no significant difference between the levels of goal quality and service engagement. Future research trialling the use of goal based outcomes in youth services would seem valuable. Strengthening an already existing practice such as goal setting, may be a simple, cost effective tool to refine services and measure client-identified outcomes. The final study used a prospective cross-sectional sample of 107 help-seeking young people aged years. This study expanded on the analyses of vocational role participation by exploring potential correlates of vocational participation and role function quality, with a focus on neurocognitive capacity. Although on the whole, participants performed below average compared with normative data on a range of tests, only strategy score on the spatial working memory task remained significantly associated with the level of vocational participation once demographic and clinical variables were controlled for. Supportive of findings in from the chart audit, factors such as not completing secondary education and recent cannabis use were significantly correlated with both the quality of role function and the level of engagement. Other factors also identified were a family history of schizophrenia or bipolar disorder, and parental occupational or socioeconomic background. Findings in the chart audit did not identify gender as a predictor of vocational participation, however, in this study being male was predictive of reduced quality and participation rates. It is possible that the differentiation in outcomes between genders only emerges in the post-school age cohort. This study would not support interventions targeting cognitive improvements in this cohort as overall deficits did not influence function. However, congruent with other studies 174

195 in this thesis, interventions focusing on educational attainment and drug counselling seem imperative Limitations There are a number of limitations and challenges with this thesis. Firstly, there was a reliance on cross-sectional data. Although this allowed an analysis of rates and correlates of presenting issues and vocational functioning variables, the data could not show causal relationships. This would have been particularly useful to help understand the trajectory of vocational participation and the influence of factors such as drug use and the emergence of distress and symptoms of mental illness. Participants in studies one and three were selfselected. Study one was a qualitative analysis, exploratory in nature and extrapolation of results was not the aim of the study. Results from this study were followed up by the second study, which used consecutive chart auditing thus eliminating self-selection bias. Participants in study three were also self-selected and due to recruitment strategies were likely to be engaging in ongoing intervention with headspace, although this was not formally assessed. Without knowing the total number of young people years old who accessed the two headspace centres during the study recruitment period, representativeness of the sample is unknown. The second study conducted in this thesis collected data from clinical charts. This method did not allow validation of the accuracy of data from the research team. Although the services used a standardised process, the information disclosed and recorded is dependent on the skill of the interviewer, their perception of importance and the willingness and openness of the participant. During this study, attempts were made to identify reasons for 175

196 disengagement from clinical charts. This information was not particularly useful as more than a quarter of young people could not be contacted to determine motivation for disengagement. Understanding reasons why young people disengage from services prematurely could provide novel insights into motivations for help-seeking and may assist services to develop strategies to improve retention rates Clinical implications and future research This thesis has made a novel contribution to the field of youth mental health by highlighting the high rates of concern about role function that coexist with psychological reasons for seeking help. It explored the role of executive function, sustained attention and reflection impulsivity on work and study outcomes, and identified goal setting as a tool, potentially underutilised in key youth services, for identifying and evaluating client-driven outcomes. Prior studies reviewing one main reason for help-seeking have reported much lower rates of help-seeking for relationship and work or study issues than young people presented with in this thesis [24]. It is important for clinicians, service managers and policy makers to not allow acute psychological presentations to overshadow the other needs of these young people presenting. In order to allow more assertive and targeted treatment, future research could explore potential clustering of issues and characteristics to identify subgroups that may be either more vulnerable to social exclusion or behavioural difficulties. One method to encourage the focus of service provision on meaningful, real-world outcomes for clients is through effective goal setting. Goal setting was regularly used in youth services participating in this thesis and reportedly in the Jigsaw service in Ireland [52]. However, the goals being 176

197 set at entry to the service are not adequately specific or measureable to evaluate attainment of client-desired outcomes. Services may already be providing the most appropriate interventions, though without assessment of meaningful outcomes the effectiveness of services remains unknown. To date, headspace has reported improvements in social and occupational function for a third of clients using the clinician-rated Social and Occupational Functioning Assessment Scale (SOFAS) [268]. Contemporary youth services pride themselves on a youth-centred service provision and the use of tools such as the SOFAS as the sole evaluation method for functional change seems at odds with this philosophy. The impact of treatment on goal attainment or at the very least client-identified functional concerns seems paramount in evaluating meaningful individualised change that is recognised by the young person. The trial of Goal Attainment Scaling found this approach to be valuable and motivating for the young people involved. Ownership and physical location of goal setting forms was particularly important to participants. Young people wanted copies of their goals, and they reported ways they might use the form to maintain motivation for goal attainment and measure success. Not surprisingly this is echoed in public mental health services, where clients report they perceive goal sheets to be owned by mental health staff, reducing their motivation to complete the goal setting tasks and relevance to therapy [299]. Strengthening goal setting practices already occurring in youth services by setting goals that are specific and measurable, providing clients with copies of the agreed goals and adding a mechanism for goal evaluation and feedback may prove a cost-effective method to: (i) identify clientcentred needs; (ii) stimulate motivation for behaviour change; and (iii) evaluate clientdesired outcomes. 177

198 The general focus on functional concerns and presenting issues was narrowed down to explore correlates of total or partial disengagement from work and study. Approximately 52% of year olds sampled were not in employment or education full-time. This high number of young people not engaged in vocational roles or restricting their engagement to part-time should be an immediate cause for concern. Positive employment experiences are routinely reported as a fundamental component in maintaining positive psychological health in young people [8, 243]. Cognitive functioning has been identified as impacting on level of functioning, including work and study outcomes, in people experiencing mental illness and other health conditions [43, 100]. Study three provided the first evidence of the impact of neurocognitive function in a diagnostically broad help-seeking youth population. The results from this thesis would not support investment in treatments such as cognitive remediation as once other demographic and clinical variables were controlled for, the individual neurocognitive domains assessed impacted very little on vocational role function. However, this study did not include a global measure of functional cognition which may provide greater correlation with function. The results did however, highlight a few key predictors and correlates of restricted vocational participation. Firstly drug use, particularly recent cannabis use, was correlated with a reduced amount and quality of vocational participation. Alcohol and drug support, similar to vocational interventions, is inconsistent between headspace services, dependent on the skills and interests of the clinicians, and in-kind support from service partners. A consistent, evidence-based model of care for young people experiencing ill effects of drug and alcohol use may prove to be a valuable adjunct to the focused psychological strategies most commonly provided by these contemporary youth mental health services. Another key 178

199 predictor of vocational participation was secondary completion rates. This is well researched in the literature [92], and programs supporting vulnerable young people to either complete their secondary education or transition to vocational training may make a considerable difference to longer term occupational outcomes. As well as drug use and age at school completion, the young people most at risk were also those with an immediate family member with a diagnosed severe mental illness, parents with low socioeconomic backgrounds and males. Service disengagement rates and predictors would also be an important area of future research, as the preliminary data reported in study two suggested young people who disengage prematurely from youth mental health services are also experiencing greater role dysfunction and disadvantage. Potential reasons for this could include poor organisational skills, competing priorities, engagement in unsupportive social behaviours, poor role modelling and personal lack of motivation or commitment. Future research could consider assessing intention to engage in therapy and role function to identify those who want to engage with services but experience greater barriers, as this group may warrant more flexible or assertive service delivery. Likewise, assessing commitment and motivation for attendance may provide insight into the need for novel strategies during the assessment session to improve motivation for those most ambivalent or negative towards ongoing helpseeking. If the service could predict those individuals most likely to disengage after the assessment session, it may be more effective to maximise the assessment session to provide brief solution-focused intervention during this initial appointment and include information regarding online resources. 179

200 In summary, key recommendations for clinicians working in primary youth mental health services based on this research include: Young people are likely to present with a variety of issues. Clinicians should ensure outcomes are evaluated using measures identifying psychological as well as functional change. Tools used to evaluate outcomes should be meaningful for the young person and client-identified. Goal-based outcomes is one method that is acceptable to young people and if used effectively may not only support evaluation of treatment but also improve engagement with the service and motivate the young person for behaviour change. Not working or studying was correlated with a number of other factors indicative of dysfunction or disadvantage such as lower than expected educational attainment, drug use and service disengagement. Assertive engagement or innovate intervention models may need to be considered for this group including community outreach and online engagement. Vocational counselling or support should consider the capacity of the young person to formulate and implement an effective strategy for task success. 180

201 References 1. Australian Institute of Health and Welfare, Young Australians: their health and wellbeing., AIHW, Editor. 2007: Canberra. 2. Arnett, J.J., Emerging adulthood: A theory of development from the late teens through the twenties. American Psychologist, (5): p Luna, B. and Sweeney, J.A. Studies of brain and cognitive maturation through childhood and adolescence: A strategy for testing neurodeveolpmental hypothesis. Schizophrenia Bulletin, (3): p Paus, T., et al., Maturation of white matter in the human brain: a review of magnetic resonance studies. Brain Research Bulletin, (3): p Nagy, Z., Westerberg, H., and Klingberg, T. Maturation of White Matter is Associated with the Development of Cognitive Functions during Childhood. Journal of Cognitive Neuroscience, (7): p Rickwood, D.J., et al., Young people's help-seeking for mental health problems. Australian e-journal for the Advancement of Mental Health, (3 Supplement). 7. Walker, E.F., Sabuwalla, Z., and Huot, R. Pubertal neuromaturation, stress sensitivity, and psychopathology. Development and Psychopathology, (04): p Schulenberg, J.E., Bryant, A.L., and O'Malley, P.M., Taking hold of some kind of life: How developmental tasks relate to trajectories of well-being during the transition to adulthood. Development and Psychopathology, (04): p Stone, A.L., et al., Review of risk and protective factors of substance use and problem use in emerging adulthood. Addictive Behaviors, (7): p Schulenberg, J.E., Sameroff, A.J., and Cicchetti, D. The transition to adulthood as a critical juncture in the course of psychopathology and mental health. Development and Psychopathology, (04): p Mossakowski, K.N., Unfulfilled expectations and symptoms of depression among young adults. Social Science & Medicine, (5): p Overbeek, G., et al., Young adults relationship transitions and the incidence of mental disorders. Social Psychiatry and Psychiatric Epidemiology, (12): p

202 13. Hopwood, C.J., et al., Genetic and environmental influences on personality trait stability and growth during the transition to adulthood: A three-wave longitudinal study. Journal of Personality and Social Psychology, (3): p Blonigen, D.M., et al., Stability and change in personality traits from late adolescence to early adulthood: A longitudinal twin study. Journal of Personality, (2): p Patel, V., et al., Mental health of young people: a global public-health challenge. The Lancet, (9569): p Kessler, R.C., et al., Lifetime prevalence and age-of-onset distributions' of DSM-IV disorders in the national comorbidity survey replication. Archives of General Psychiatry, (6): p Rickwood, D.J., Raphael, B., and Pilgrim, D. Promoting youth mental health through early intervention. Advances in Mental Health, (1): p Australian Health Ministers, Fourth National Mental Health Plan: An agenda for collaborative government action in mental health , Commonwealth Department of Health and Aging: Canberra. 19. Rickwood, D.J., Promoting youth mental health: priorities for policy from an Australian perspective. Early Intervention in Psychiatry, (Suppl. 1): p Catania, L.S., et al., Prevention and early intervention for mental health problems in 0-25 year olds: Are there evidence-based models of care? Advances in Mental Health, (1): p Hampshire, A. and Di Nicola, K. What's worrying young Australians and where do they go for advice and support? Policy and practice implications for thier well-being. Early Intervention in Psychiatry, (Suppl. 1): p McGorry, P., et al., headspace: Australia's National Youth Mental Health Foundation - where young minds come first. Medical Journal of Australia, (7): p. S Rickwood, D.J., Deane, F.P., and Wilson, C.J. When and how do young people seek professional help for mental health problems? Medical Journal of Australia, (7): p. S35-S Rickwood, D.J., et al., Headspace Australia s innovation in youth mental health: who are the clients and why are they presenting. Medical Journal of Australia, (2): p

203 25. Greer, T.L., Kurian, B.T., and Trivedi, M.H. Defining and Measuring Functional Recovery from Depression. CNS Drugs, (4): p McLaren, C. and Rodger, S. Goal attainment scaling: Clinical implications for paediatric occupational therapy practice. Australian Occupational Therapy Journal, (4): p Carr, V.J., et al., Costs of schizophrenia and other psychoses in urban Australia: findings from the Low Prevalence (Psychotic) Disorders Study. Australian and New Zealand Journal of Psychiatry, (1): p Schlosser, D.A., et al., Recovery From an At-Risk State: Clinical and Functional Outcomes of Putatively Prodromal Youth Who Do Not Develop Psychosis. Schizophrenia Bulletin, (6): p Gotlib, I.H., Lewinsohn, P.M., and Seeley, R.J., Symptoms versus a diagnosis of depression: Differences in psychosocial functioning. Journal of Consulting and Clinical Psychology, (1): p Carrión, R.E., et al., Impact of neurocognition on social and role functioning in individuals at clinical high risk for psychosis. American Journal of Psychiatry, : p Kessler, R.C., et al., Social Consequences of Psychiatric Disorders, I: Educational Attainment. American Journal of Psychiatry, (7): p O'Dea, B., et al., A cross-sectional exploration of the clinical characteristics of disengaged (NEET) young people in primary mental healthcare. BMJ Open, (12). 33. Australian Institute of Health and Welfare, Australia's welfare , AIHW: Canberra. 34. Hamilton, B.A., et al., Disability is already pronounced in young people with early stages of affective disorders: Data from an early intervention service. Journal of Affective Disorders, (1 3): p Bachman, P., et al., Processing speed and neurodevelopment in adolescent-onset psychosis: Cognitive slowing predicts social functioning. Journal of Abnormal Child Psychology, : p Sawyer, M.G., et al., Mental Health of Young People in Australia. 2000, Commenwealth Department of Health and Aged Care: Canberra. 183

204 37. Brown, S.A. and Tapert, S.F. Adolescence and the trajectory of alcohol use: Basic to clinical studies, in Adolescent Brain Development: Vulnerabilities and Opportunities, R.E. Dahl and L.P. Spear, Editors p Maggs, J.L. and Schulenberg, J.E. A developmental perspective on alcohol use and heavy drinking during adolescence and the transition to young adulthood *, in Journal of Studies on Alcohol Supplement p. S Schimmelmann, B.G., et al., Pre-treatment, baseline, and outcome differences between early-onset and adult-onset psychosis in an epidemiological cohort of 636 first-episode patients. Schizophrenia Research, (1 3): p Koutsouleris, N., et al., Early Recognition and Disease Prediction in the At-Risk Mental States for Psychosis Using Neurocognitive Pattern Classification. Schizophrenia Bulletin, (6): p Seidman, L.J., et al., Neuropsychological Functioning in Adolescents and Young Adults at Genetic Risk for Schizophrenia and Affective Psychoses: Results from the Harvard and Hillside Adolescent High Risk Studies. Schizophrenia Bulletin, (3): p van Oel, C.J., et al., School Performance as a Premorbid Marker for Schizophrenia: A Twin Study. Schizophrenia Bulletin, (3): p Kalechstein, A.D., Newton, T.F., and van Gorp, W.G. Neurocognitive functioning is associated with employment status: A quantitative review. Journal of Clinical and Experimental Neuropsychology, (8): p Andresen, R., Oades, L., and Caputi, P. The Experience of Recovery from Schizophrenia: Towards an Empirically Validated Stage Model. Australian and New Zealand Journal of Psychiatry, (5): p Lloyd, C., King, R., and Bassett, H. A Survey of Australian Mental Health Occupational Therapists. British Journal of Occupational Therapy, (2): p Locke, E.A. and Latham, G.P. New Directions in Goal-Setting Theory. Current Directions in Psychological Science, (5): p Ponte-Allan, M. and Giles, G.M. Goal setting and functional outcomes in rehabilitation. American Journal of Occupational Therapy, : p Kiresuk, T., Smith, A., and Cardillo, J.E. eds. Goal Attainment Scaling: Applications, Theory, and Measurement. 1994, Lawrence Erlbaum Associates: Hillsdale. 184

205 49. Lewinsohn, P.M., et al., Adolescent psychopathology.1. Prevelance and incidence of depression and other DSM-III-R disorders in high school students. Journal of Abnormal Psychology, (1): p Birmaher, B., et al., Childhood and adolescent depression: A review of the past 10 years.1. Journal of the American Academy of Child and Adolescent Psychiatry, (11): p Shanahan, M.J., Pathways to Adulthood in Changing Societies: Variability and Mechanisms in Life Course Perspective. Annual Review of Sociology, (1): p O'Reilly, A., et al., Youth engagement with an emerging Irish mental health early intervention programme (Jigsaw): participant characteristics and implications for service delivery. Journal of Mental Health, (5): p McGorry, P., Bates, T. and Birchwood, M. Designing youth mental health services for the 21st century: examples from Australia, Ireland and the UK. The British Journal of Psychiatry, (s54): p. s30-s Schuster, C., et al., Adolescent marijuana use and adult occupational attainment: A longitudinal study from age 18 to 28. Substance Use & Misuse, (8): p Lynskey, M., Substance use and educational attainment. Addiction, (12): p Lynskey, M., et al., A longitudinal study of the effects of adolescent cannabis use on high school completion. Addiction, (5): p Oliver, M.I., et al., Help-seeking behaviour in men and women with common mental health problems: cross-sectional study. The British Journal of Psychiatry, (4): p Dooley, B. and Fitzgerald, A. My World Survey: National study of youth mental health in Ireland. 2012, UCD School of Psychology: Dublin, Ireland. 59. Hickie, I., Youth mental health: we know where we are and can now say where we need to go next. Early Intervention in Psychiatry, : p Slade, T., et al., The Mental Health of Australians 2: Report on the 2007 National Survey of Mental Health and Wellbeing, Department of Health and Ageing, Editor. 2009: Canberra. 185

206 61. Armando, M., et al., Psychotic experience subtypes, poor mental health status and help-seeking behaviour in a community sample of young adults. Early Intervention in Psychiatry, (3): p McGorry, P., Innovations in the design of mental health services for young people: an Australian perspective. Innovation and Entrepreneurship in Health, : p Iyer, S.N., et al., Transforming youth mental health: a Canadian perspective. Irish Journal of Psychological Medicine, (Special Issue 01): p Allison, S., Bastiampillai, T., and Goldney, R. Australia s national youth mental health initiative: Is headspace underachieving? Australian and New Zealand Journal of Psychiatry, (2): p Jorm, A.F., How effective are headspace youth mental health services? Australian and New Zealand Journal of Psychiatry, (10): p Patulny, R., et al., Are we reaching them yet? Service access patterns among attendees at the headspace youth mental health initiative. Child and Adolescent Mental Health, (2): p McGorry, P.D., et al., Response to Jorm: Headspace A national and international innovation with lessons for redesign of mental health care in Australia. Australian and New Zealand Journal of Psychiatry, (1): p Lawrence, D., et al., The Mental Health of Children and Adolescents. Report on the second Australian Child and Adolescent Survey of Mental Health and Wellbeing., Department of Health, Editor. 2015: Canberra. 69. Jorm, A.F., Headspace: The gap between the evidence and the arguments. Australian and New Zealand Journal of Psychiatry, (3): p Mental Health Commission of Canada, Taking the Next Step Forward: Building a Responsive Mental Health and Addictions System for Emerging Adults. 2015, Mental Health Commission of Canada: Ottowa, ON. 71. O'Brien, A., Fahmy, R., and Singh, S.P. Disengagement from mental health services. Social Psychiatry and Psychiatric Epidemiology, (7): p Doyle, R., et al., First-Episode Psychosis and Disengagement From Treatment: A Systematic Review. Psychiatric Services, (5): p

207 73. Rickwood, D.J., et al., The services provided to young people by headspace centres in Australia. Medical Journal of Australia, (10): p Organisation for Economic Cooperation and Development, Off to a good start? Jobs for Youth Krahn, H.J., Howard, A.L., and Galambos, N.L. Exploring or Floundering? The Meaning of Employment and Educational Fluctuations in Emerging Adulthood. Youth & Society, (2): p Baum, S. and Mitchell, W. Adequate employment, underutilisation and unemployment: an analysis of labour force outcomes for Australian youth. Australian Journal of Labour Economics, (3): p McKee-Ryan, F., et al., Psychological and Physical Well-Being During Unemployment: A Meta-Analytic Study. Journal of Applied Psychology, (1): p Morris, A. and Wilson, S. Struggling on the Newstart unemployment benefit in Australia: The experience of a neoliberal form of employment assistance. The Economic and Labour Relations Review, Bynner, J. and Parsons, S., Social Exclusion and the Transition from School to Work: The Case of Young People Not in Education, Employment, or Training (NEET). Journal of Vocational Behavior, (2): p Scott, J., et al., Adolescents and young adults who are not in employment, education, or training. British Medical Journal, Carvalho, P., Youth Unemployment in Australia, in CIS research report; , Centre for Independent Studies. 82. Bowman, D., Borlagdan, J., and Bond, S., Making sense of youth transitions from education to work. 2015, Brotherhood of St Laurence, Fitzroy, Vic. 83. Junankar, P., The Impact of the Global Financial Crisis on Youth Labour Markets, in Discussion Paper Series. 2014, Institute for the Study of Labour (IZA): Bonn, Germany. 84. Healy, J., The Australian labour market in 2014: Still ill? Journal of Industrial Relations, (3): p Bexley, E., et al., University student finances in 2012: A study of the financial circumstances of domestic and interantional students in Australia's universities. 2013, Centre for the Study for Higher Education: The University of Melbourne. 187

208 86. Ciairano, S., et al., Adolescent substance use in two European countries: Relationships with psychosocial adjustment, peers, and activities. International Journal of Clinical and Health Psychology, (1): p Rapee, R.M., et al., Annual Research Review: Conceptualising functional impairment in children and adolescents. Journal of Child Psychology and Psychiatry, (5): p Reupert, A.E., Maybery, D.J., and Kowalenko, N.M., Children whose parents have a mental illness prevalence, need and treatment. Medical Journal of Australia Open, (Suppl 1): p Sadler, K., Akister, J., and Burch, S., Who are the young people who are not in education, employment or training? An application of the risk factors to a rural area in the UK. International Social Work, (4): p Benjet, C., et al., Youth who neither study nor work: mental health, education and employment. Salud Pública de México, : p OECD, Education at a Glance 2015: OECD Publishing. 92. Killackey, E.J., et al., Exciting career opportunity beckons! Early intervention and vocational rehabilitation in first-episode psychosis: employing cautious optimism. Australian & New Zealand Journal of Psychiatry, (11/12): p Jablensky, A., Epidemiology of schizophrenia: the global burden of disease and disability. European Archives of Psychiatry and Clinical Neuroscience, (6): p McGrath, J., et al., Schizophrenia: A Concise Overview of Incidence, Prevalence, and Mortality. Epidemiologic Reviews, (1): p Hafner, H., et al., The influence of age and sex on the onset and early course of schizophrenia. British Journal of Psychiatry, : p Simon, A.E., et al., Cognitive Functioning in the Schizophrenia Prodrome. Schizophrenia Bulletin, (3): p Heinrichs, R.W. and Zakzanis, K.K., Neurocognitive deficit in schizophrenia: a Quantitative review of the evidence. Neuropsychology, (3): p Cornblatt, B.A., et al., Preliminary Findings for Two New Measures of Social and Role Functioning in the Prodromal Phase of Schizophrenia. Schizophrenia Bulletin, (3): p

209 99. Puig, O., et al., Processing speed and executive functions predict real-world everyday living skills in adolescents with early-onset schizophrenia. European Child & Adolescent Psychiatry, (6): p Cornblatt, B.A., et al., The Schizophrenia Prodrome Revisited: A Neurodevelopmental Perspective. Schizophrenia Bulletin, (4): p Hawkins, K.A., et al., Neuropsychological status of subjects at high risk for a first episode of psychosis. Schizophrenia Research, : p Smith, C.W., Park, S., and Cornblatt, B., Spatial working memory deficits in adolescents at clinical high risk for schizophrenia. Schizophrenia Research, (2 3): p Yung, A.R., et al., Risk factors for psychosis in an ultra high-risk group: psychopatholgy and clinical features. Schizophrenia Research, : p Cornblatt, B.A., et al., Risk Factors for Psychosis: Impaired Social and Role Functioning. Schizophrenia Bulletin, (6): p Kelleher, I., et al., Identification and characterisation of prodromal risk syndromes in young adolescents in the community: A population based clinical interview study. Schizophrenia Bulletin, (2): p Nakagami, E., Hoe, M., and Brekke, J.S., The Prospective Relationships Among Intrinsic Motivation, Neurocognition, and Psychosocial Functioning in Schizophrenia. Schizophrenia Bulletin, (5): p Robles, O., et al., Cognitive efficacy of quetiapine and olanzapine in early-onset firstepisode psychosis. Schizophrenia Bulletin, (2): p Ballageer, T., et al., Is adolescent-onset first-episode psychosis different from adult onset? Journal of the American Academy of Child & Adolescent Psychiatry, (8c): p Robinson, D., et al., Predictors of relapse following response from a first episode of schizophrenia or schizoaffective disorder. Archives of General Psychiatry, (3): p Cannon, T.D., Cornblatt, B., and McGorry, P., Editor's Introduction: The Empirical Status of the Ultra High-Risk (Prodromal) Research Paradigm. Schizophrenia Bulletin, (3): p

210 111. Yung, A.R., et al., Mapping the onset of psychosis: the Comprehensive Assessment of At-Risk Mental States. Australian and New Zealand Journal of Psychiatry, : p Yung, A.R., et al., Declining Transition Rate in Ultra High Risk (Prodromal) Services: Dilution or Reduction of Risk? Schizophrenia Bulletin, (3): p Warner, R., Problems with early and very early intervention in psychosis. The British Journal of Psychiatry, (48): p. s104-s McGlashan, T.H., Early detection and intervention in psychosis: an ethical paradigm shift. The British Journal of Psychiatry, (48): p. s113-s Stefanis, N.C., et al., Evidence that three dimensions of psychosis have a distribution in the general population. Psychological Medicine, : p Scott, J., et al., Demographic correlates of psychotic-like experiences in young Australian adults. Acta Psychiatrica Scandinavica, (3): p Spencer, E., Birchwood, M., and McGovern, D., Management of first-episode psychosis. Advances in Psychiatric Treatment, (2): p Addington, J., et al., At clinical high risk for psychosis: Outcome for nonconverters. American Journal of Psychiatry, (8): p Johns, L.C. and van Os, J., The continuity of psychotic experiences in the general population. Clinical Psychology Review, (8): p Barnett, J.H., et al., Childhood cognitive function and adult psychopathology: associations with psychotic and non-psychotic symptoms in the general population. British Journal of Psychiatry, (2): p van Os, J., et al., A systematic review and meta-analysis of the psychosis continuum: evidence for a psychosis proneness-persistence-impairment model of psychotic disorder. Psychological Medicine, (2): p Kim, S.J., et al., The relationship between psychotic-like experiences and attention deficits in adolescents. Journal of Psychiatric Research, (10): p Konings, M.B., et al., Validity and reliability of the CAPE: a self-report insturment for the measurement of psychotic experiences in the general population. Acta Psychiatrica Scandinavica, : p

211 124. Nishida, A., et al., Associations between psychotic-like experiences and mental health status and other psychopathologies among Japanese early teens. Schizophrenia Research, (1 3): p Rickwood, D.J. and d'espaignet, E.T., Psychological distress among older adolescents and young adults in Australia. Australian and New Zealand Journal of Public Health, (1): p Goldberg, D., The detection of psychiatric illness by questionnaire. 1972, London: Oxford University Press Lee, Y.J., et al., The relationship between psychotic-like experiences and sleep disturbances in adolescents. Sleep Medicine, (8): p Andrews, G. and Wilkinson, D.D., The prevention of mental disorders in young people. Medical Journal of Australia, : p. S97-S Baune, B.T., et al., Neuropsychological performance in a sample of year olds with a history of non-psychotic major depressive disorder. Journal of Affective Disorders, (2-3): p Maalouf, F.T., et al., Neurocognitive impairment in adolescent major depressive disorder: State vs. trait illness markers. Journal of Affective Disorders, (3): p Beblo, T., Sinnamon, G., and Baune, B.T., Specifying the neuropsychology of affective disorders: Clinical, demographic and neurobiological factors. Neuropsychology Review, (4): p Lewinsohn, P.M., Rohde, P., and Seeley, J.R., Major depressive disorder in older adolescents: Prevalence, risk factors, and clinical implications. Clinical Psychology Review, (7): p Kyte, Z.A., Goodyer, I.M., and Sahakian, B.J., Selected executive skills in adolescents with recent first episode major depression. Journal Of Child Psychology And Psychiatry, And Allied Disciplines, (9): p Hermens, D.F., et al., Impaired verbal memory in young adults with unipolar and bipolar depression. Early Intervention in Psychiatry, (3): p Torres, I.J., et al., Neurocognitive Functioning in Patients With Bipolar I Disorder Recently Recovered From a First Manic Episode. Journal of Clinical Psychiatry, (9): p

212 136. Jansen, K., et al., Early functional impairment in bipolar youth: A nested populationbased case-control study. Journal of Affective Disorders, (1 3): p Derdikman-Eiron, R., et al., Gender differences in psychosocial functioning of adolescents with symptoms of anxiety and depression: longitudinal findings from the Nord-Trondelag Health Study. Social Psychiatry and Psychiatric Epidemiology, (11): p Jonsson, U., et al., Intimate relationships and childbearing after adolescent depression: a population-based 15 year follow-up study. Social Psychiatry and Psychiatric Epidemiology, (8): p Killackey, E., Jackson, H.J., and McGorry, P., Vocational intervention in first-episode psychosis: individual placement and support v. treatment as usual. The British Journal of Psychiatry, (2): p Waghorn, G., et al., A multi-site randomised controlled trial of evidence-based supported employment for adults with severe and persistent mental illness. Australian Occupational Therapy Journal, (6): p Sunderland, M., et al., Estimating the Prevalence of DSM-IV Mental Illness in the Australian General Population Using the Kessler Psychological Distress Scale. Australian & New Zealand Journal of Psychiatry, (10): p Ellis, B.J., et al., The evolutionary basis of risky adolescent behavior: Implications for science, policy, and practice. Developmental Psychology, (3): p Moffitt, T.E., Adolescence-limited and life-course-persistent antisocial behavior: A developmental taxonomy. Psychological Review, (4): p Harvanko, A.M., et al., Cognitive Task Performance and Frequency of Alcohol Usage in Young Adults. Journal of Addiction Medicine, (2): p Grattan-Miscio, K.E. and Vogel-Sprott, M., Effects of alcohol and performance incentives on immediate working memory. Psychopharmacology, (1): p Leroi, I., Sheppard, J.M., and Lyketsos, C.G., Cognitive function after 11.5 years of alcohol use: Relation to alcohol use. American Journal of Epidemiology, (8): p

213 147. Sullivan, E.V., Rosenbloom, M.J., and Pfefferbaum, A., Pattern of motor and cognitive deficits in detoxified alcoholic men. Alcoholism-Clinical and Experimental Research, (5): p Moss, H.B., Special section: Alcohol and adolescent brain development. Alcoholism- Clinical and Experimental Research, (3): p Ellickson, P.L., Tucker, J.S., and Klein, D.J., Ten-year prospective study of public health problems associated with early drinking. Pediatrics, (5): p Aertgeerts, B. and Buntinx, F., The relation between alcohol abuse or dependence and academic performance in first-year college students. Journal of Adolescent Health, (3): p Singleton, R.A., Collegiate alcohol consumption and academic performance. Journal of Studies on Alcohol and Drugs, (4): p Thombs, D.L., et al., Undergraduate Drinking and Academic Performance: A Prospective Investigation With Objective Measures. Journal of Studies on Alcohol and Drugs, (5): p Clark, D.B., Thatcher, D.L., and Tapert, S.F., Alcohol, psychological dysregulation, and adolescent brain development. Alcoholism-Clinical and Experimental Research, (3): p Australian Institute of Health and Welfare, Statistics on drug use in Australia , AIHW: Canberra Johnston, L.D., et al., Monitoring the Future. National results on adolescent drug use: Overview of key findings, , Institute for Social Research, The University of Michigan: Ann Arbor Degenhardt, L., et al., Toward a Global View of Alcohol, Tobacco, Cannabis, and Cocaine Use: Findings from the WHO World Mental Health Surveys. PLoS Med, (7): p. e Lisdahl, K.M. and Price, J.S., Increased Marijuana Use and Gender Predict Poorer Cognitive Functioning in Adolescents and Emerging Adults. Journal of the International Neuropsychological Society, (04): p Schweinsburg, A.D., Brown, S.A., and Tapert, S.F., The Influence of Marijuana Use on Neurocognitive Functioning in Adolescents. Current Drug Abuse Reviews, (1): p

214 159. Ringel, J.S., Ellickson, P.L., and Collins, R.L., High school drug use predicts job-related outcomes at age 29. Addictive Behaviors, (3): p Grant, J.E., et al., Neuropsychological deficits associated with cannabis use in young adults. Drug and Alcohol Dependence, (1-2): p Hyggen, C., Does smoking cannabis affect work commitment? Addiction, (7): p Green, K. and Ensminger, M.E., Adult social behavioral effects of heavy adolescent marijuana use among African Americans. Developmental Psychology, (6): p Weiss, J.W., et al., Association between psychological factors and adolescent smoking in seven cities in China. International Journal of Behavioral Medicine, (2): p Harvey, M.A., et al., The relationship between non-acute adolescent cannabis use and cognition. Drug and Alcohol Review, (3): p Pope, H.J., et al., Neuropsychological performance in long-term cannabis users. Archives of General Psychiatry, (10): p Pope, H.J. and Yurgelun-Todd, D., The residual cognitive effects of heavy marijuana use in college students. JAMA: The Journal of the American Medical Association, (7): p Lyons, M.J., et al., Neuropsychological consequences of regular marijuana use: a twin study. Psychological Medicine, (07): p Gruber, S.A., et al., Age of Onset of Marijuana Use and Executive Function. Psychology of Addictive Behaviors, (3): p Tait, R.J., Mackinnon, A., and Christensen, H., Cannabis use and cognitive function: 8- year trajectory in a young adult cohort. Addiction, (12): p Solowij, N., et al., Verbal learning and memory in adolescent cannabis users, alcohol users and non-users. Psychopharmacology, (1): p Fontes, M.A., et al., Cannabis use before age 15 and subsequent executive functioning. British Journal of Psychiatry, (6): p Hanson, K.L., et al., Impact of Adolescent Alcohol and Drug Use on Neuropsychological Functioning in Young Adulthood: 10-Year Outcomes. Journal of Child & Adolescent Substance Abuse, (2): p

215 173. Dingwall, K.M., et al., Cognitive recovery during and after treatment for volatile solvent abuse. Drug and Alcohol Dependence, (2 3): p Medina, K.L., Shear, P.K., and Corcoran, K., Ecstasy (MDMA) exposure and neuropsychological functioning: A polydrug perspective. Journal of the International Neuropsychological Society, (06): p NSW Department of Education and Training, Sniffing: The dangers of solvent use by young people, Science and Training, Commonwealth Department of Education, Editor. 2002, Australian Government Publishing Service: Canberra Saha, S., et al., The association between delusional-like experiences, and tobacco, alcohol or cannabis use: a nationwide population-based survey. BMC Psychiatry, (1): p Schubart, C.D., et al., Cannabis use at a young age is associated with psychotic experiences. Psychological Medicine, (06): p McGorry, P., Killackey, E., and Yung, A.R., Early intervention in psychosis: concepts, evidence and future directions. World Psychiatry, (3): p Malla, A. and Payne, J., First-Episode Psychosis: Psychopathology, Quality of Life, and Functional Outcome. Schizophrenia Bulletin, (3): p Judd, L.L., et al., Psychosocial disability during the long-term course of unipolar major depressive disorder. Archives of General Psychiatry, (4): p Bickman, L., et al., Two low-cost measures of child and adolescent functioning for services research. Evaluation and Program Planning, (3): p Burlingame, G.M., et al., Pragmatics of Tracking Mental Health Outcomes in a Managed Care Setting. Journal of Mental Health Administration, (3): p Bickman, L., A Measurement Feedback System (MFS) Is Necessary to Improve Mental Health Outcomes. Journal of the American Academy of Child & Adolescent Psychiatry, : p Kazdin, A.E., Evidence-Based Assessment for Children and Adolescents: Issues in Measurement Development and Clinical Application. Journal of Clinical Child & Adolescent Psychology, (3): p

216 185. Warren, J.S., et al., Youth psychotherapy change trajectories and outcomes in usual care: Community mental health versus managed care settings. Journal of Consulting and Clinical Psychology, (2): p Weisz, J.R., et al., Youth top problems: Using idiographic, consumer-guided assessment to identify treatment needs and to track change during psychotherapy. Journal of Consulting and Clinical Psychology, (3): p Edbrooke-Childs, J., et al., Interpreting standardized and idiographic outcome measures in CAMHS: what does change mean and how does it relate to functioning and experience? Child and Adolescent Mental Health, (3): p Law, M., et al., The Canadian Occupational Performance Measure: An Outcome Measure for Occupational Therapy. Canadian Journal of Occupational Therapy, (2): p Stevens, A., et al., The use of patient-specific measurement instruments in the process of goal-setting: a systematic review of available instruments and their feasibility. Clinical Rehabilitation, (11): p Fuller, K., The effectiveness of occupational performance outcome measures within mental health practice. British Journal of Occupational Therapy, (8): p Blum R W M., Healthy Youth Development as a Model for Youth Health Promotion: A Review. Journal of Adolescent Health, (5): p Cotton, S., et al., Group programmes in early intervention services. Early Intervention in Psychiatry, : p Johnson, R.B. and Onwuegbuzie, A.J, Mixed Methods Research: A Research Paradigm Whose Time Has Come. Educational Researcher, (7): p Andrew, S. and E.J. Halcomb, Mixed methods research is an effective method of enquiry for community health research. Contemporary Nurse, (2): p Rickwood, D.J., et al., Changes in psychological distress and psychosocial functioning in young people accessing headspace centres for mental health problems. Medical Journal of Australia, (10): p National Youth Mental Health Foundation. headspace overview. 2016; Available from: 196

217 197. Kiresuk, T.J. and Sherman, R.E., Goal attainment scaling: A general method for evaluating comprehensive community mental health programs. Community Mental Health Journal, (6): p Kleinrahm, R., et al., Assessing change in the behavior of children and adolescents in youth welfare institutions using goal attainment scaling. Child and Adolescent Psychiatry and Mental Health, (1): p Donnelly, C. and Carswell, A., Individualized outcome measures: A review of the literature. The Canadian Journal of Occupational Therapy, (2): p Hurn, J., Kneebone, I., and Cropley, M., Goal setting as an outcome measure: a systematic review. Clinical Rehabilitation, (9): p Tennant, A., Goal attainment scaling: Current methodological challenges. Disability & Rehabilitation, (20/21): p Kessler, R.C., et al., Short screening scales to monitor population prevalences and trends in non-specific psychological distress. Psychological Medicine, (6): p Berle, D.B., et al., The Factor Structure of the Kessler-10 Questionnaire in a Treatment-Seeking Sample. Journal of Nervous & Mental Disease, (9): p Fulbrook, P. and Lawrence, P., Survey of an Australian general emergency department: estimated prevalence of mental health disorders. Journal of Psychiatric and Mental Health Nursing, (1): p Australian Bureau of Statistics, Use of the Kessler Psychological Distress Scale in ABS Surveys, Australia, , Commonwealth of Australia: Canberra, ACT Slade, T., Grove, R., and Burgess, P., Kessler Psychological Distress Scale: normative data from the 2007 Australian National Survey of Mental Health and Wellbeing. Australian & New Zealand Journal of Psychiatry, (4): p McMillan, J., Beavis, A., and Jones, F.L., A new socioeconomic index for Australia. Journal of Sociology, (2): p Piskulic, D., et al., Using the global functioning social and role scales in a first-episode sample. Early Intervention in Psychiatry, (3): p

218 209. Sahakian, B.J. and Owen, A.M., Computerised assessment in neuropsychiatry using CANTAB: discussion paper. Journal of the Royal Society of Medicine, : p Cambridge Cognition, Neuropsychological Test Automated Battery (CANTABeclipse) manual. 2006, Cambridge: Cambridge Cognition Limited Roque, D.T., et al., The use of the Cambridge Neuropsychological Test Automated Battery (CANTAB) in neuropsychological assessment: Application in Brazilian research with control children and adults with neurological disorders. Psychology & Neuroscience, (2): p Luciana, M., Practitioner Review: Computerized assessment of neuropsychological function in children: clinical and research applications of the Cambridge Neuropsychological Testing Automated Battery (CANTAB). Journal of Child Psychology and Psychiatry, (5): p Fray, P.J., Robbins, T.W., and Sahakian, B.J., Neuorpsychiatyric applications of CANTAB. International Journal of Geriatric Psychiatry, (4): p Lin, Y.J., Chen, W.J., and Gau,S.S., Neuropsychological functions among adolescents with persistent, subsyndromal and remitted attention deficit hyperactivity disorder. Psychological Medicine, (8): p Lawrence, A.J., et al., Problem gamblers share deficits in impulsive decision-making with alcohol-dependent individuals. Addiction, (6): p Waber, D.P., et al., The NIH MRI study of normal brain development: Performance of a population based sample of healthy children aged 6 to 18 years on a neuropsychological battery. Journal of the International Neuropsychological Society, (5): p Owen, A.M., et al., Planning and spatial working memory following frontal lobe lesions in man. Neuropsychologia, (10): p Smith, P.J., et al., A comparison of the Cambridge Automated Neuropsychological Test Battery (CANTAB) with traditional neuropsychological testing instruments. Journal of Clinical and Experimental Neuropsychology, (3): p Syvaoja, H.J., et al., Internal Consistency and Stability of the CANTAB Neuropsychological Test Battery in Children. Psychological Assessment, (2): p

219 220. CANTAB reliability study. 2003, Cambridge Cognition Limited Lezak, M.D., Howieson, D.B., and Loring, D.W., Neuropsychological assessment. 4th ed. 2004, New York: Oxford University Press Ford, S., et al., Neurocognitive Correlates of Problem Behaviour in Environmentally At-Risk Adolescents. Journal of Developmental & Behavioural Pediatrics, : p Delongis, D., Continuous Performance Test. 1991, Santa Anita: Wang Laboratories Sahgal, A., Some limitations of indices derived from signal detection theory: evaluation of an alternative index for measuring bias in memory tasks. Psychopharmacology, (4): p Petrides, M. and Milner, B., Deficits on subject-ordered tasks after frontal- and temporal-lobe lesions in man. Neuropsychologia, (3): p Khurana, A., et al., Early Adolescent Sexual Debut: The Mediating Role of Working Memory Ability, Sensation Seeking, and Impulsivity. Developmental Psychology, (5): p Conklin, H.M., et al., Working Memory Performance in Typically Developing Children and Adolescents: Behavioral Evidence of Protracted Frontal Lobe Development. Developmental Neuropsychology, (1): p Clark, L., et al., Reflection Impulsivity in Current and Former Substance Users. Biological Psychiatry, (5): p Yung, A.R., et al., Psychotic-like experiences in a community sample of adolescents: implications for the continuum model of psychosis and prediction of schizophrenia. Australian & New Zealand Journal of Psychiatry, (2): p Armando, M., et al., Psychotic-like experiences and correlation with distress and depressive symptoms in a community sample of adolescents and young adults. Schizophrenia Research, (1 3): p Capra, C., et al., Brief screening for psychosis-like experiences. Schizophrenia Research, : p Brener, N.D., et al., Reliability of the 1999 Youth Risk Behaviour Survey questionnaire. Journal of Adolescent Health, : p Winters, K.C., et al., Validity of adolescent self-report of alcohol and other drug involvement. International Journal of the Addictions, (11A): p

220 234. Eaton, D.K., et al., Youth Risk Behaviour Surveillance - United States, Morbidity and Mortality Weekly Report, (4): p Swahn, M.H., et al., Psychosocial characteristics associated with frequent physical fighting: findings from the 2009 National Youth Risk Behavior Survey. Injury Prevention, (2): p Lee, S.Y., et al., Substance abuse precedes internet addiction. Addictive Behaviors, (4): p Mission Australia, National survey of young Australians 2011: Key and emerging issues. 2011, Mission Australia Queensland Government, Queensland Plan for Mental Health , Queensland Government: Brisbane Smith, J.A. and Osborn, M., Interpretative Phenomenolgical Analysis, in Qualitative Psychology: A Practical Guide to Research Methods, J.A. Smith, Editor. 2008, Sage Publications Ltd: London Pope, C. and Mays, N., Reaching the parts other methods cannot reach: an introduction to qualitative methods in health and health services research. British Medical Journal, : p Patton, M.Q., Qualitative Research & Evaluation Methods. 3 ed. 2002, Thousand Oaks: Sage Publications, Inc Boldero, J. and Fallon, B., Adolescent help-seeking: what do they get help for and from whom? Journal of Adolescence, (2): p Blustein, D.L., The role of work in psychological health and well-being - A conceptual, historical, and public policy perspective. American Psychologist, (4): p Graetz, B., Health consequences of employment and unemployment, in Youth in the eighties. Papers from the Australian Longitudinal Survey Resarch Project., R.G. Gregory and T. Karmel, Editors. 1992, Centre for Economic Policy Research: Canberra. p McGorry, P., The specialist youth mental health model: strengthening the weakest link in the public mental health system. Med J Aust, (7 Suppl): p. S Killackey, E., Something for everyone: employment interventions in psychotic illness. Acta Neuropsychiatrica, (5): p

221 247. Morrell, S.L., Taylor, R.J., and Kerr, C.B., Unemployment and young people's health. Medical Journal of Australia, (5): p Cairns, A., et al., Exploring functional concerns in help-seeking youth: a qualitative study. Early Intervention in Psychiatry, (3): p Australian Institute of Health and Welfare, Young Australians: their health and wellbeing , Australian Institute of Health and Welfare: Canberra Wanberg, C.R., The Individual Experience of Unemployment, in Annual Review of Psychology, Vol 63, S.T. Fiske, D.L. Schacter, and S.E. Taylor, Editors. 2012, Annual Reviews: Palo Alto. p Baggio, S., et al., Not in Education, Employment, or Training Status Among Young Swiss Men. Longitudinal Associations With Mental Health and Substance Use. Journal of Adolescent Health, (2): p Helgesson, M., et al., Unemployment at a young age and later sickness absence, disability pension and death in native Swedes and immigrants. European Journal of Public Health, (4): p Wilkins, R., The Extent and Consequences of Underemployment in Australia Australian Bureau of Statistics, Labour force, detailed - electronic delivery, March Day, J.C. and Newburger, E.C., The Big Payoff: Educational attainment and sythetic estimates of work-life earnings. Special studies., U.S.D.o. Commerce, Editor. 2002, Economics and Statistics Administration: Washington, DC Kennedy, S., Stoney, N., and Vance,L., Labour force participation and the influence of educational attainment. Economic Round-up, : p Australian Institute of Health and Welfare, Australia's health 2012, AIHW, Editor. 2012, AIHW: Canberra Iyer, S.N., et al., An examination of patient-identified goals for treatment in a firstepisode programme in Chennai, India. Early Intervention in Psychiatry, (4): p National Statistics of the United Kingdom, Youth cohort study and the longitudinal study of young people in England: the activities and experiences of 18-year-olds - England 2009., D.f. Education, Editor. 2010, National Statistics. 201

222 260. Hannan, D.F., Ó Riain, S., and Whelan, C.T., Youth unemployment and psychological distress in the Republic of Ireland. Journal of Adolescence, (3): p Yung, A.R., et al., Psychotic-Like Experiences in Nonpsychotic Help-Seekers: Associations With Distress, Depression, and Disability. Schizophrenia Bulletin, (2): p Scott, J., et al., Psychotic-like experiences in the general community: the correlates of CIDI psychosis screen items in an Australian sample. Psychological Medicine, (02): p Han, G., et al., Selective neurocognitive impairments in adolescents with major depressive disorder. Journal of Adolescence, (1): p Castaneda, A.E., et al., A review on cognitive impairments in depressive and anxiety disorders with a focus on young adults. Journal of Affective Disorders, (1 2): p Solowij, N., et al., Reflection impulsivity in adolescent cannabis users: a comparison with alcohol-using and non-substance-using adolescents. Psychopharmacology, (2): p Tapert, S.F. and Brown, S.A., Neuropsychological correlates of adolescent substance abuse: Four-year outcomes. Journal of the International Neuropsychological Society, (06): p Myles-Worsley, M., et al., The Palau Early Psychosis Study: Neurocognitive functioning in high-risk adolescents. Schizophrenia Research, (1 3): p Rickwood, D.J., et al., Changes in psychological distress and psychosocial functioning in young people visiting headspace centres for mental health problems. Medical Journal of Australia, (10): p Luciana, M., et al., Tower of London Performance in Healthy Adolescents: The Development of Planning Skills and Associations With Self-Reported Inattention and Impulsivity. Developmental Neuropsychology, (4): p Gould, F., et al., The effects of child abuse and neglect on cognitive functioning in adulthood. Journal of Psychiatric Research, (4): p

223 271. De Luca, C.R., et al., Normative Data From the Cantab. I: Development of Executive Function Over the Lifespan. Journal of Clinical and Experimental Neuropsychology, (2): p Irvine, M.A., et al., Impaired decisional impulsivity in patholgoical videogamers. PLoS One, (10): p. e Carrion, R.E., et al., The impact of psychosis on the course of cognition: a prospective, nested case-control study in individuals at clinical high-risk for psychosis. Psychological Medicine, : p Iselin, A.-M.R. and DeCoster, J., Unique relations of age and delinquency with cognitive control. Journal of Adolescence, (2): p Miyaguchi, K., et al., Cognitive training for delinquents within a residential service in Japan. Children and Youth Services Review, (9): p Tchanturia, K. and Lock, J., Cognitive Remediation Therapy for Eating Disorders: Development, Refinement and Future Directions, in Behavioral Neurobiology of Eating Disorders, R.A.H. Adan and W.H. Kaye, Editors. 2011, Springer-Verlag Berlin: Berlin. p Mezzacappa, E. and Buckner, J., Working Memory Training for Children with Attention Problems or Hyperactivity: A School-Based Pilot Study. School Mental Health, (4): p Anaya, C., et al., A systematic review of cognitive remediation for schizo-affective and affective disorders. Journal of Affective Disorders, (1-3): p Andresen, R., Caputi, P., and Oades, L.J., Do clinical outcome measures assess consumer-defined recovery? Psychiatry Research, (3): p Renju, J. and Birchwood, M., The national policy reforms for mental health services and the story of early intervention services in the United Kingdom. Journal of Psychiatry & Neuroscience, (5): p Centre for Mental Health, et al., No Health Without Mental Health: Implementation Framework., Department of Health., Editor. 2012: London Carroll, A., et al., Goal setting among adolescents: A comparison of delinquent, atrisk, and not-at-risk youth. Journal of Educational Psychology, (3): p

224 283. McCormack, C. and Collins, B., Can disability studies contribute to client-centred occupational therapy practice? British Journal of Occupational Therapy, (7): p Maitra, K.K. and Erway, F., Perception of client-centered practice in occupational therapists and their clients. American Journal of Occupational Therapy, (3): p Steenbeek, D., et al., Goal attainment scaling in paediatric rehabilitation: a critical review of the literature. Developmental Medicine & Child Neurology, (7): p Turnbull, J., Evaluating health care using goal attainment scaling. Nursing Standard, (42): p Stolee, P., et al., Clinical Experience with Goal Attainment Scaling in Geriatric Care. Journal of Aging and Health, (1): p Young, C.A., Manmathan, G.P., and Ward, J.C.R., Perceptions of Goal Setting in a Neurological Rehabilitation Unit: A Qualitative Study of Patients, Carers and Staff. Journal of Rehabilitation Medicine, : p Willig, C., Introducing qualitative research in psychology (2nd ed.). 2nd ed. 2008, Maidenhead, England: McCraw-Hill Deane, H. and Young, S., Navigating Adolescence: An Epidemiological Follow-Up of Adaptive Functioning in Girls With Childhood ADHD Symptoms and Conduct Disorder. Journal of Attention Disorders, (1): p Pfeiffer, J.P. and Pinquart, M., Goal engagement and goal attainment in adolescents with and without visual impairment. Journal of Adolescence, (4): p Locke, E.A. and Latham, G.P., Building a practically useful theory of goal setting and task motivation: A 35-year odyssey. American Psychologist, (9): p Evans, J.J., Goal setting during rehabilitation early and late after acquired brain injury. Current Opinion in Neurology, (6): p Lindstrom, M., Hariz, G.M., and Bernspang, B., Dealing With Real-Life Challenges: Outcome of a Home-Based Occupational Therapy Intervention for People With Severe Psychiatric Disability. Occupation Participation and Health, (2): p

225 295. Bertolote, J. and McGorry, P., Early intervention and recovery for young people with early psychosis: consensus statement. The British Journal of Psychiatry, (48): p. s116-s Australian Government, National Standards for Mental Health Services. 2010: Barton Beck, J., Cognitive Behavior Therapy: Basics and Beyond. Second ed. 2011, New York: The Guilford Press Killackey, E., Psychosocial and psychological interventions in early psychosis: essential elements for recovery. Early Intervention in Psychiatry, : p. S17-S Marshall, S.L., Oades, L.G., and Crowe, T.P., Australian mental health consumers' contributions to the evaluation and improvement of recovery oriented service provision. Israel Journal of Psychiatry and Related Sciences, (3): p Bovend'Eerdt, T.J.H., Botell, R.E., and Wade, D.T., Writing SMART rehabilitation goals and achieving goal attainment scaling: a practical guide. Clinical Rehabilitation, (4): p Scott, J., et al., Functional impairment in adolescents and young adults with emerging mood disorders. British Journal of Psychiatry, (5): p Lloyd, C. and Waghorn, G., The Importance of Vocation in Recovery for Young People with Psychiatric Disabilities. British Journal of Occupational Therapy, (2): p Waghorn, G., Lloyd, C., and Clune, A., Reviewing the theory and practice of occupational therapy in mental health rehabilitation. British Journal of Occupational Therapy, (7): p Levack, W.M.M., et al., Is goal planning in rehabilitation effective? A systematic review. Clinical Rehabilitation, (9): p Cairns, A., et al., Setting measurable goals with young people: Qualitative feedback from the Goal Attainment Scale in youth mental health. British Journal of Occupational Therapy, (4): p Rosewilliam, S., Roskell, C.A., and Pandyan, A.D., A systematic review and synthesis of the quantitative and qualitative evidence behind patient-centred goal setting in stroke rehabilitation. Clinical Rehabilitation, (6): p

226 307. King, L.A. and Burton, C.M., The hazards of goal pursuit, in Virtue, vice, and personality: The complexity of behavior., E.C. Chang, et al., Editors. 2003, American Psychological Association: Washington, DC, US. p Jacob, J., et al., Horses for courses? A qualitative exploration of goals formulated in mental health settings by young people, parents, and clinicians. Clinical Child Psychology and Psychiatry, (2): p Appleton, J.J., et al., Measuring cognitive and psychological engagement: Validation of the Student Engagement Instrument. Journal of School Psychology, (5): p Greene, B.A., et al., Predicting high school students' cognitive engagement and achievement: Contributions of classroom perceptions and motivation. Contemporary Educational Psychology, (4): p Corrigan, P.W., et al., Strategies for Disseminating Evidence-Based Practices to Staff Who Treat People With Serious Mental Illness. Psychiatric Services, (12): p Wade, D.T., Goal setting in rehabilitation: an overview of what, why and how, in Clinical Rehabilitation. 2009, Sage Publications Inc. p Law, D. and Jacob, J., Goals and Goal Based Outcomes (GBOs): Some Useful Information (third edition), Child Outcomes Research Consortium (CORC). Editor. 2015, Press CAMHS: London. 206

227 Appendices Table of Contents A1 Ethical approval A1.1 Ethical approval certificate A2 Study one data collection tools A2.1 Participant questionnaire A2.2 Interview schedule A3 Study two data collection tools A3.1 Chart audit data collection tool A4 Study three experimental measures A4.1 Participant questionnaire A4.2 Kessler Psychological Distress Scale A4.3 Community Assessment of Psychic Experiences (CAPE-P) A4.4 Global Functioning Role scale A4.5 Vocational participation questionnaire A4.6 Youth Behaviour Risk Survey (modified) A5 Participant Information and Consent Forms A5.1 Study one A5.2 Study three

228 Appendix One: Ethical approval A1.1 Ethical approval for this program of research was granted by the Queensland University of Technology Human Research Ethics Committee. Study one ethical approval number Study two and three ethical approval number

229 209

230 Appendix Two: Study one data collection tools Chapter 4 and 8 A2.1 Participant questionnaire: Functional concerns and goal setting for help-seeking young Australians 1. Year of birth (age): 2. Gender: F M 3. Diagnosis? 4. Referral source? 5. Occupational status: work school other training neither Fulltime part-time hrs/week approx.. 6. Living situation: Alone parents other family member friends 210

231 A2.2 Interview schedule: Semi Formal Interview Questions GUIDE ONLY. 1. Are there any areas of your life that you are having difficulty with? 2. What are the specific problems that you are most concerned about? 3. Can you think of any other areas of your life that are not going as you would hope? eg. work, school/training, friends, family life, fun. 4. Out of these concerns which ones do you most hope headspace can help you with? Try and pick 1 or 2 things that you are most focused on? 5. What are the things that are going really well in your life that you don t need any support with? 6. Have you ever done any goal setting with headspace staff before? 7. Do you think you could turn those concerns into areas to work on ie. goals? Introduce Goal Attainment Scaling form and complete. 8. How easy was this to do? 9. What was difficult/bad about going through this form? 10. Do you think it would be useful? 11. Do you think this scale would be a good measure of the success of your involvement in headspace? 211

232 Appendix Three: Study two data collection tools Chapter 5, 6 and 9 A3.1 Chart audit data collection tool: Intake and Assessment Chart Audit Data Collection Tool Profile of help-seeking youth Age Collection 1 Inala 2 Southport site Gender 0 Female 1 Male Mental Health diagnosis 0 no 1 yes Diagnosis: Medication 0 no 1 yes Family Hx MH 0 no 1 yes Diagnosis: Current or previous alcohol use 0 no 1 yes Current or previous drug use 0 no 1 yes Lives with 1 Both parents 2 one parent 3 Other family 4 Foster family 5 Friends 6 Share house 7 Partner 8 Alone Other... Living arrangement 1 temporary 2 permanent Relationship 0 no 1 yes Children 0 no 1 yes Children live at home 0 no 1 yes Vocational information Current student 0 no 1 yes If yes 1 High School 2 TAFE 3 University 4 Other training facility 1 Full time 2 Part time Current highest level of attainment 1 Yr 12 or higher 2 Yr 11 3 Yr 10 4 Yr 9 5 Yr 8 or below Currently in paid employment 0 no 1 yes 212

233 If yes 1 Full time 2 Part time 3 casual 3 Home duties Unpaid employment 0 no 1 yes If yes 1 volunteer work 2 home duties/carer 3 other: Receiving benefits 0 no 1yes Clinical information Number of services received Intake/assessment only Psychology GP Psychiatric assessment Other... Predominant issues? 1 Psychological 2 Physical health 3 Vocational 4 Living arrangement 5 Social/Relationships 6 Other... K10 score Goals recorded? 0 no 1 yes List goals: 213

234 Appendix Four: Study three experimental measures Chapter 7 A4.1 Participant questionnaire What is your current age? Gender? 0 Female 1 Male What is your identified ethnicity? Do you have a mental health diagnosis? 0 No 1 Yes If yes, what is the diagnosis 1 Depression 2 Anxiety 3 Bipolar Disorder 4 Schizophrenia 5 Other Do you have any other medical/health condition? 0 No 1 Yes If yes, what? Do you take any medication? 0 No 1 Yes If yes, what? Has anyone in your immediate family ever been treated for a 0 No 1 Yes mental illness? If yes, what was the illness? 1 Depression 2 Anxiety 3 Bipolar Disorder 4 Schizophrenia 5 Other: What is the highest level of education you have completed? 1 University degree 2 Post-school diploma 3 Post-school trade certificate 4 Year 12 5 Year 11 6 Year 10 7 Year 9 8 Year 8 or below Do you expect to achieve a higher level of education? 0 No 1 Yes Are you currently working towards this? 0 No 1 Yes What best describes your relationship status? 1 Single 2 In a relationship 3 Defacto/married 4 Divorced 214

235 What best describes your living situation? Parent occupation (main earner): 5 Widowed 1 Alone 2 With partner 3 Parents/guardian 4 Other family member 5 Friends 6 Other Mother: Father: 215

236 A4.2 Kessler Psychological Distress Scale 216

237 A4.3 Community Assessment of Psychic Experiences - Positive Symptom (CAPE-P) Questions 1. Have you ever felt as if people seem to drop hints about you or say things with a double meaning Never (1) Sometimes (2) Often (3) Nearly always (4) 2. Have you ever felt as if things in magazines or on TV were written especially for you? 3. Have you ever felt as if some people are not what they seem to be? 4. Have you ever felt that you are being persecuted in anyway? 5. Have you ever felt as if there is a conspiracy against you? 6. Have you ever felt as if you are destined to be someone very important? 7. Have you ever felt that you are a very special or unusual person? 8. Have you ever thought that people can communicate telepathically? 9. Have you ever felt as if electrical devices such as computers can influence the way you think? 10. Have you ever believed in the power of witchcraft, voodoo or the occult? 11. Have you ever felt that people look at you oddly because of your appearance? 12. Have you ever felt as if the thoughts in your head are being taken away from you? 13. Have you ever felt as if the thoughts in your head are not your own? 14. Have your thoughts ever been so vivid that you were worried other people would hear them? 15. Have you ever heard your thoughts being echoes back at you? 16. Have you ever felt as if you are under the control of some force or power other than yourself? 17. Have you ever heard voices when you are alone? 18. Have you ever heard voices talking to each other when you are alone? 19. Have you ever felt as if a double has taken place of a family member, friend or acquaintance? 20. Have you ever seen objects, people or animals that other people can't see? Questions 21. Overall, how distressed are these experiences making you feel? Not distressed A bit distressed Quite distressed Very distressed 217

238 A4.4 Global Functioning Role scale (GFR) Prompts for GF: Role Scale Specific questions to aid in rating the GF: Role scale are provided below. Be sure to assess for changes in role functioning over the previous year (to rate highest and lowest) as well as current functioning within the past month. Determine and rate functioning for primary role setting (work, school, or home) based upon questions below. However, if the subject is engaged in multiple roles, consider total amount of time spent in role-related activities (ie, part-time school plus part-time work equals full-time role status). 1. How do you spend your time during the day? 2. If currently working: a. Where do you work? What are your job responsibilities? b. How many hours a week do you work? c. How long have you been in your current job? Have you had any recent changes in your job status (eg, lost job, stopped working, changed position, or workload)? d. Do you usually need assistance or regular supervision at work? How often do you need extra help? Are there any tasks that you are not able to do alone? e. Do you ever have trouble keeping up? Are you able to catch up if you fall behind? f. Have you received any comments (positive or negative) or formal reviews regarding your performance? Have others pointed out things that you have done well or poorly? 3. If currently attending school: a. What type of school do you attend? (general education, nonpublic school, residential/hospital) b. Have you ever been in special education classes or other nongeneral education classes? c. How long have you been at this school? Have you had any recent changes in your school placement? d. Do you receive any extra help or accommodations in your classes? Do you receive tutoring or extra help in school or after school? Do you receive extra time to take tests or are you able to leave the classroom to take tests in a quiet place? e. Do you have trouble keeping up with your coursework? Are you able to catch up if you fall behind? f. How are your grades? Are you failing any classes? 4. If a homemaker: a. What are your responsibilities around the house or for the family? b. How long have you been in charge of the home? c. How many hours per week do you spend working on household tasks? d. Are you able to keep up with the demands of your household? Do you ever fall behind? If so, are you able to catch up or do you need others help? Are you avoiding any tasks? Do you need regular assistance or supervision for any tasks within the home? e. Have you received any comments (positive or negative)regarding your performance? Have others pointed out things that you have done well or poorly? Reference: Cornblatt, B. A., Auther, A. M., Niendam, T., Smith, C. W., Zinberg, J., Bearden, C. E., & Cannon, T. D. (2007). Preliminary Findings for Two New Measures of Social and Role Functioning in the Prodromal Phase of Schizophrenia. Schizophrenia Bulletin, 33(3), doi: /schbul/sbm

239 GF: Role scale scoring Superior role functioning 10. Independently maintains superior functioning in demanding roles. Obtains only superior performance evaluations at competitive work placement. Obtains all A s in mainstream school. Generates, organizes, and completes all homemaking tasks with ease. Above average role functioning 9 Independently maintains very good functioning in demanding roles. Rarely absent or unable to perform. Obtains good to superior performance evaluations at competitive work placement. Obtains grades in A and B range in all courses in mainstream school. Generates, organizes, and completes all homemaking tasks. Good role functioning 8 Independently maintains good role functioning in demanding roles. Occasionally falls behind on tasks but always catches up; obtains satisfactory performance evaluations at competitive work placement; obtains grades of C and above in mainstream school; occasional difficulty generating or organizing homemaking tasks; or maintains above average performance with minimal support (eg, tutoring, reduced academic course load at 4-year university, attends community college, may receive additional guidance at work less than 1 2 times a week). Receives As and Bs, good work/school evaluations, and completes all tasks with this level of support. Mild impairment in role functioning 7 Mildly impaired functioning in demanding roles independently. Frequently behind on tasks or unable to perform; frequently obtains poor performance evaluations at competitive work placement or grades of Ds or better in mainstream school; frequent difficulty generating or organizing homemaking tasks; or maintains good performance with minimal support (eg, minimal accommodations in general education classroom, receives additional guidance/support at work 1 2 times a week). Receives Cs or higher, satisfactory work/school evaluations, and completes most homemaking tasks with this level of support. Moderate impairment in role functioning 6 Moderate impairment independently. May receive occasional F in mainstream courses, persistently poor performance evaluations at competitive work placement; may change jobs because of poor performance, persistent difficulty generating, or organizing homemaking tasks; or requires partial support (some resource or special education courses, receives guidance/support at work 2+ times per week). May require less demanding or part-time jobs and/or some supervision in home environment but functions well or adequately given these supports (may fall behind but eventually completes assigned tasks, obtains satisfactory evaluations at work or passing grades in school). Serious Impairment in Role Functioning 5 Serious impairment independently. Failing multiple courses in mainstream school, may lose job, or unable to complete most homemaking tasks independently; or in entirely special education classes, requires less demanding job/daily support or guidance, may require vocational rehabilitation, and/or some supervision in home environment but maintains above average performance receives As and Bs, good evaluations at work/school, completes all tasks. Major impairment in role functioning 4 Very serious impairment independently. All Fs in mainstream school or failing out of school; cannot obtain or hold independent job or unable to complete virtually any homemaking tasks independently; or adequate to good functioning with major support. Requires assisted work environment, entirely special education classes, nonpublic or psychiatric school, home schooling for the purpose of a supportive school environment, and/or supported home environment but functions adequately given these supports (may fall behind but completes assigned tasks, obtains satisfactory performance evaluations at work or passing grades). Marginal ability to function 3 Impaired functioning with major support. Requires supported work environment, entirely special education classes, nonpublic or psychiatric school, home schooling for the purpose of a supportive school environment, and/or supported home environment but functions poorly despite these supports (persistently behind on tasks, frequently unable to perform, obtains poor performance evaluations at work or fails courses at school). Inability to function 2 Disabled but participates in structured activities. On disability or equivalent nonindependent status. Not working for pay, attending classes for grades, or living independently. Spends 5 or more hours a week in structured role-related activities (eg, residential treatment, volunteering, tutoring, sheltered work programs). 219

240 Extreme role dysfunction 1 Severely disabled. On disability or equivalent nonindependent status. Not working for pay, attending classes for grades, or living independently. Spends fewer than 5 hours a week in structured role-related activities. 220

241 A4.5 Vocational participation questionnaire What best describes you? 1 Not working or studying. No volunteer work or home care responsibilities. 2 Working part-time or studying part-time or have home care responsibilities (primarily responsible for children). Total hours less than 30/week. 3 Working or studying full-time (30+hours/week). 4 Working part-time and studying part-time (30+ hours/week) 5 Studying/working full-time and studying/working as well. 221

242 A4.6 Youth Behaviour Risk Survey (modified) 1. During the past 30 days, on how many days did you smoke cigarettes? 0 days 1 or 2 days 3 to 5 days 6 to 9 days 10 to 19 days 20 to 29 days All 30 days 2. During your life, on how many days have you had at least one drink of alcohol? (This includes drinking beer, wine, wine coolers and liquor such as rum, gin, vodka or whiskey. For these questions, drinking alcohol does not include drinking a few sips of wine for religious purposes.) 0 days 1 or 2 days 3 to 9 days 9 to 19 days 20 to 39 days 40 to 99 days 100 days or more 3. During the past 30 days, on how many days did you have at least one drink of alcohol? 0 days 1 or 2 days 3 to 5 days 6 to 9 days 10 to 19 days 20 to 29 days All 30 days 4. During the past 30 days, on how many days did you have 5 or more drinks of alcohol in a row, that is, within a couple of hours? 0 days 1 or 2 days 3 to 5 days 6 to 9 days 10 to 19 days 20 to 29 days All 30 days 5. During your life, how many times have you used cannabis? (Cannabis is also called marijuana, weed or pot.) 0 times 1 or 2 times 3 to 9 times 10 to19 times 20 to 39 times 40 to 99 times 100 or more times 6. During the past 30 days, how many times did you use cannabis? 0 times 1 or 2 times 3 to 9 times 10 to 19 times 20 to 39 times 40 or more times 7. During your life, how many times have you used other drugs like ecstasy, methamphetamines (speed, ice), cocaine, hallucinogens (LSD), heroin etc? 0 times 1 or 2 times 3 to 9 times 10 to 19 times 20 to 39 times 40 or more times 222

243 Appendix Five: Participant information and Consent Forms A5.1 Study one PARTICIPANT INFORMATION FOR QUT RESEARCH PROJECT Interview Functional concerns and goal setting for help seeking young Australians QUT Ethics Approval Number RESEARCH TEAM Principal Researcher: Associate Researchers: Alice Hodgson, PhD student, Queensland University of Technology (QUT) Dr Steven McPhail, QUT Dr Frances Dark, Metro South Mental Health, Queensland Health Professor David Kavanagh, QUT DESCRIPTION This project is part of a university research degree (PhD) for Alice Hodgson. We are hoping to find out what practical concerns (eg. work, school, friends) young people have who are seeking support from headspace. We will find out if there are common areas of concern that young people have. We will also ask you to think of a goal which you think headspace can help you with. Then we want your opinion on how useful it is to set goals using a goal setting process called Goal Attainment Scaling (GAS). Goal Attainment Scaling is a way people can evaluate the progress of goals. You are invited to participate in this project because you attend headspace. PARTICIPATION Your participation is entirely voluntary. If you do agree to participate, you can change your mind without comment or penalty. If you withdraw, any information with your name on it will be destroyed. Your decision to participate or not participate, will in no way effect your current or future relationship with QUT or with headspace. What do I have to do? Have a casual interview with the principal researcher which will take about 30minutes. This will be audio taped and the interview will happen at headspace Gold Coast, 26 Railway Street, Southport. Questions will be about what areas of your life you are having difficulty with and from these which ones do you hope headspace can help you with. Once you have identified one problem/concern that you hope headspace can help you with, you will be asked if you could set a goal for yourself around this area of concern. You will then be asked a few extra questions about how useful it was to set a goal. EXPECTED BENEFITS Although it is not expected that this project will benefit you directly, it may help you to reflect on your goals and communicate these with their headspace counsellor more clearly If you participant, the research team is offering participants the chance to win a $100 itunes or Myer gift voucher. RISKS This project involves a 1:1 interview about personal aspects of your life. The questions are about practical things in your life that you are having trouble with but they do not require you to reveal more than you feel comfortable. You may feel nervous talking about yourself to someone you don t know. This is normal but if you feel this nervousness is too much we will pause the interview, the interviewer will reassure you about the process and give you time to 223

244 think about if you would like to continue. If you have any special strategies you use when you feel anxious you can use these during the interview. At any time during the interview you can stop without penalty and you can choose not to answer questions if you don t want to. If the interviewer is really concerned they might stop the interview anyway. If this happens you will be asked to remain in the interview room until your usual headspace counsellor or someone of your choosing can talk to you. The interview should take 30 minutes. We will try and keep to this time by not asking you questions that are not directly related to this project. PRIVACY AND CONFIDENTIALITY All your answers will be private. You don t have to name any names when answering any of the questions. The interview will be audio recorded; this recording will be typed up word for word by the interviewer (Alice Hodgson) with all names removed to protect your identity. The recordings will be destroyed after they have been typed out. Unfortunately you cannot participate if you do not agree to the interview being recorded. CONSENT TO PARTICIPATE We would like to ask you to sign the consent form (enclosed) to confirm you agree to participate and understand what is involved. QUESTIONS / FURTHER INFORMATION ABOUT THE PROJECT If have any questions or require any further information about the project please contact one of the research team members below. Alice Hodgson, PhD student Dr Steven McPhail School of Public Health Faculty of Health School of Public Health Centre for Functioning and Health Research Faculty of Health alice.hodgson@student.qut.edu.au steven.mcphail@qut.edu.au CONCERNS / COMPLAINTS REGARDING THE CONDUCT OF THE PROJECT QUT is committed to research integrity and the ethical conduct of research projects. However, if you do have any concerns or complaints about the ethical conduct of the project you may contact the QUT Research Ethics Unit on or ethicscontact@qut.edu.au. The QUT Research Ethics Unit is not connected with the research project and can facilitate a resolution to your concern in an impartial manner. Thank you for helping with this research project. Please keep this sheet for your information. 224

245 CONSENT FORM FOR QUT RESEARCH PROJECT Interview Functional concerns and goal setting for young Australians QUT Ethics Approval Number RESEARCH TEAM CONTACTS Alice Hodgson, PhD student Dr Steven McPhail School of Public Health Faculty of Health School of Public Health Centre for Functioning and Health Research Faculty of Health Dr Frances Dark Professor David Kavanagh Consultant Psychiatrist Metro South Mental Health Service School of Psychology and Counselling Faculty of Health QUT STATEMENT OF CONSENT If you would like a copy of the final research manuscript please provide your name and or postal address below. This will not be a copy of your personal interview but the report collating the outcome from all the interviews. STATEMENT OF CONSENT By signing below, you are indicating that you: Have read and understood the information document regarding this project. Have had any questions answered to your satisfaction. Understand that if you have any additional questions you can contact the research team. Understand that you are free to withdraw at any time, without comment or penalty. Understand that you can contact the Research Ethics Unit on or ethicscontact@qut.edu.au if you have concerns about the ethical conduct of the project. Understand that the project will include audio recording. Agree to participate in the project. Name Signature Date Postal address Please return this sheet to the investigator. 225

246 A5.2 Study three PARTICIPANT INFORMATION FOR QUT RESEARCH PROJECT Is there a relationship between thinking skills and work or study skills in young Australians? QUT Ethics Approval Number RESEARCH TEAM Principal Researcher: Alice Cairns PhD student, Queensland University of Technology (QUT) Associate Researchers: Dr Steven McPhail QUT Dr Frances Dark Metro South Mental Health, Queensland Department of Health Professor David Kavanagh QUT DESCRIPTION This project is part of a university research degree (PhD) for Alice Cairns. We are hoping to find out if thinking skills (memory, attention) and other experiences (like feeling emotionally overwhelmed) are related to study or work skills. We also want to find out if these thinking skills are related to unusual or odd thinking. You are invited to participate in this project because you attend Headspace and you are over 18 years old. PARTICIPATION What do I have to do? We will ask you to answer some basic questions about yourself for example: What is the highest level of education completed? We will then ask you to fill out five checklists asking about different experiences in your life. Questions will include your alcohol and drug use, how you feel about your life, if you have any weird thoughts (e.g. Have you ever thought that people can communicate telepathically?), and how you are going with work or study. This should take about 30minutes. You will also be asked to complete some memory, problem solving and attention tests on a computer. These take about 1 hour but there is no time limit. This means you can stop for breaks as often as like. I have attached pictures of what two of these computer tests look like at the back of this form. There are 5 tests in total. Everything will happen at your usual Headspace clinic, Gold Coast: 26 Railway Street, Southport or Inala: Shop 53, Inala Plaza 156 Inala Avenue, Inala. Your participation is entirely voluntary. If you do agree to participate, you can change your mind later without penalty. If you withdraw, you will not need to give a reason before any information with your name on it will be destroyed. Your decision to participate or not will in no way affect your current or future relationship with QUT or Headspace. EXPECTED BENEFITS 226

247 You can get the results of your computer tests if you want. If you score below average I can make a time to chat with you about these results. This is not part of the study and it is entirely up to you whether you want to do this or not. If you do, I can invite your usual Headspace health professional to join us. This might be helpful if you want to understand what these results may suggest about your life however it is up to you if you want your therapist to join us. You have to give the OK before I would do anything. Participating may or may not directly benefit you. It may indirectly benefit you by helping us understand the experiences of young adults who are seeking help from services like Headspace. In particular understanding what factors are impacting on their ability and satisfaction with work and study. If you complete all the tests you will receive a $30 Coles group and Myer shopping voucher or itunes voucher (your choice) as a thanks for your time. The Coles/Myer voucher can be redeemed and a number of stores including Coles, Myer, Target, Kmart and Officeworks. The itunes voucher can be redeemed through the itunes online store. RISKS The main risks of participation are mental fatigue and potential frustration that may cause distress with the computer tests. The researcher will be with you while you are doing the tests and at any time you can take a break or we can stop all together. You can finish the tests another day or you might not want to finish the test at all. Some people do all the tests in one go but a lot of people need breaks. The results of your tests might be confronting if you don t do as well as you might like. You don t have to get your results if you don t want. If you do want your results however and they are below average I can make a time to go through the results with you. As discussed, your Headspace counsellor can join us but only with your consent. You may feel anxious being with someone you don t know. Some of the checklists ask information that is quite personal. This is normal but if you feel this nervousness is too much we will pause the session, the interviewer will reassure you about the process and give you time to think about if you would like to continue. If you have any special strategies you use when you feel anxious you can use these during the interview. At any time you can stop without penalty and you can choose not to answer questions if you don t want to. If the interviewer is concerned about you they will stop the session anyway. If this happens you will be asked to remain in the interview room until your usual Headspace health professional or someone of your choosing can talk to you to make sure you are ok. The Headspace professionals are not part of this research. If you have any concerns about your participation and don t feel comfortable talking to the researcher, talking to one of the Headspace staff may be helpful. Alternatively, QUT provides for limited free psychology, family therapy or counselling services for research participants of QUT projects who may experience discomfort or distress as a result of their participation in the research. Should you wish to access this service please contact the Clinic Receptionist of the QUT Psychology and Counselling Clinic on Please indicate to the receptionist that you are a research participant. There are a number of other services that provide free information and counselling for people having a difficult time. These include: Life line 24 hour crisis telephone counselling: Youth beyondblue: Reach out, an interactive online forum: PRIVACY AND CONFIDENTIALITY The principal researcher will conduct all the interviews. All your answers and results are private. Your name will not be recorded on the forms anywhere. We will use a code so we know which forms belong together (i.e. all of the forms relating to you will have the same code). Nothing will be shared with your Headspace counsellor unless you have requested they participate in the debrief session. The computer test results will be collected and saved using participant codes in password protected software and database. Other assessment forms will be coded and collected in paper form, then transferred to electronic format and saved on password protected databases by the principal researcher. Paper copies of 227

248 data collection and consent forms will be kept separate in a lockable filing cabinet, in a lockable office at the research supervisor s office at the Centre for Functioning and Health Research. Only members of the research team will have access to this information. Individual information will not be used by itself, all the information from all the participants will be grouped. The grouped results from this research will be reported in the principal researcher s final PhD report, in health professional journals and at conferences or forums. CONSENT TO PARTICIPATE We would like to ask you to sign a written consent form (enclosed) to confirm your agreement to participate and understand what is involved. QUESTIONS / FURTHER INFORMATION ABOUT THE PROJECT If have any questions or require any further information please contact one of the research team members below. Alice Cairns School of Public Health and Social Work Faculty of Health Dr Steven McPhail Centre for Functioning and Health Research School of Public Health and Social Work alice.hodgson@student.qut.edu.au steven.mcphail@qut.edu.au CONCERNS / COMPLAINTS REGARDING THE CONDUCT OF THE PROJECT QUT is committed to research integrity and the ethical conduct of research projects. However, if you do have any concerns or complaints about the ethical conduct of the project you may contact the QUT Research Ethics Unit on or ethicscontact@qut.edu.au. The QUT Research Ethics Unit is not connected with the research project and can facilitate a resolution to your concern in an impartial manner. Thank you for helping with this research project. Please keep this sheet for your information. 228

249 PARTICIPANT CONSENT FORM FOR QUT RESEARCH PROJECT Is there a relationship between thinking skills and work or study skills in young Australians? QUT Ethics Approval Number RESEARCH TEAM CONTACTS Alice Cairns Dr Steven McPhail School of Public Health and Social Work Faculty of Health Centre for Functioning and Health Research School of Public Health and Social Work alice.hodgson@student.qut.edu.au steven.mcphail@qut.edu.au Dr Frances Dark Professor David Kavanagh Consultant Psychiatrist Metro South Mental Health Service School of Psychology and Counselling QUT Faculty of Health Frances.dark@health.qld.gov.au david.kavanagh@qut.edu.au STATEMENT OF CONSENT By signing below, you are indicating that you: Have read and understood the information document regarding this project. Have had any questions answered to your satisfaction. Understand that if you have any additional questions you can contact the research team. Understand that you are free to withdraw at any time, without comment or penalty. Understand that you can contact the Research Ethics Unit on or ethicscontact@qut.edu.au if you have concerns about the ethical conduct of the project. Agree to participate in the project. Name Signature Date Phone Postal/ address Please return this sheet to the investigator. 229

250 Cambridge Neuropsychological Test Automated Battery (CANTAB) Memory: Spatial working memory (SWM) Spatial working memory. A number of coloured squares (boxes) are shown on the screen. You must find blue tokens hidden in each the boxes and use them to fill up an empty column on the right hand side of the screen. The colour and position of the boxes change after each trial. Attention and new learning: Intra-extra dimensional set shift (IED) Intra-extra dimensional set shift. Four boxes are shown on the screen. In two of the boxes there are one or two patterns. One of the patterns is the correct one to point at. At first you just have to guess which one you think is correct but you soon learn through trial and error the rules to work out which pattern is correct. These are pictures of 2 of the computer tests, there are 5 tests in total 230

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