Neither seen nor heard: what about recovery for children and young people?
17th September 2014
Earlier this summer, we were contacted by the Young Person Recovery Research Group of the University of Surrey’s School of Psychology. They told us about the work that they have undertaken on the concept of recovery for children and young people. Here, they tell us about this work and their efforts to begin to develop recovery measures for young people and their families.
Young people and recovery
The idea of personal or social recovery has become a prominent aspect of mental health service design and delivery in many countries in the past decade. Advocates of personal recovery reject as overly simplistic an understanding of recovery from a mental health problem as simply being the ‘cure’ of that problem. In the main, ideas about social recovery have come from first-person accounts or primary research with adult service users experiencing severe mental illness. Any expectation that recovery principles will also be enshrined in mental health services for children and young people appears to be based on an assumption that what might be good for adults might also be good for children.
However, there have been very few published considerations of either the applicability of the idea to young people or of evidence in this area. There has been a notable lack of either theoretical or empirical work that might inform consideration of how the concept of social recovery might apply to adolescents or how it might be measured, though some Trusts have considered the issue (South London and Maudsley NHS Foundation Trust and South West London and St George’s Mental Health NHS Trust, 2010).
In England and Wales, the agenda of Every Child Matters (Department for Education and Skills, 2003) sets out hopes for children with which the recovery idea, as described for adults, would seem to be compatible such as “to enjoy and achieve” and “to make a positive contribution to society.” The same can be said for Scotland’s Getting it Right for Every Child policy with its principles referencing wellbeing, strengths and resilience. Similarities have also been noted between the idea of Recovery and the concept of Resilience, which is well-established within CAMHS services in the UK, for example. Resilience has been defined as ”normal development under difficult conditions” (Fonagy, Steele, Steele, Higgitt, and Target, 1994; Zolkoski, 2012). However, “recovery” implies more of a process than the outcomes hoped for by Every Child Matters and the skills or attributes suggested by the idea of Resilience (Alvord & Grados, 2005).
Applying the idea of recovery to young people’s mental health in the way that it has been applied to adults might be problematic. For adults, recovery can imply a return to how life was before mental ill health was experienced whereas since children are in the process of developing a sense of self, the idea of a return to prior state is not viable.
With all this in mind – and with an awareness that there has not been a body of adolescent “survivors” writing about their experiences and driving a “movement” in the way that adults have – we have been doing some work in which we have tried to explore the relevance of the idea of recovery in mental ill-health to young people and adolescents.
Measuring recovery with young people
We started with a systematic literature review that, as expected, failed to yield a body of literature on recovery in young people. We then followed this with some conceptual work speaking to young people who were or had been in contact with child and adolescent mental health services and their parents (Simonds, Pons, Stone, Warren, John, 2013). From this, we developed three measures of recovery in the context of adolescent mental health (one for young people themselves; one for the parent/carer’s view of the young person’s recovery and one for the parent/carer’s own experience of recovery (John, Jeffries, Acuna-Rivera, Warren, Simonds, 2014 in press)).
Thematic analysis of interviews conducted with nine adolescents with anxiety and depression (seven girls and two boys aged 14–16 years) and 12 mothers indicated that young people do experience a process of “recovery”; the processes participants described have some congruence with the earlier stages of adult recovery models which involve biographical disruption, the development of new meanings of anxiety or depression, and changes in sense of identity. The accounts diverge with regard to the later stages of the dominant adult models that postulate the development of hope and responsibility.
From the data collected in these interviews we devised three questionnaires. These were designed to assess the process of recovery from the perspective of the young person (the ReQuest-YP), their carer or parent (the ReQuest-PYP) and also to capture the process of recovery that a parent or carer might themselves undergo as they experience the young person’s mental ill-health. Our analysis suggested that all three measures are reliable and valid: as expected young people’s recovery scores were correlated negatively with their level of reported emotional difficulty and positively with their self-esteem. Parent and young persons’ reports of the young person’s recovery were positively correlated as were parent’s reports of their own recovery and their reports of the young person’s recovery.
Implications for services aiming to help young people in distress
Although this early work suggests that a concept of recovery is relevant to young people and that it might be measured usefully, there are some remaining questions. For example, in our interview work we did not find evidence for the later stages of the recovery model as described for adults in our data. We do not yet know if this reflects the limitations of the recovery model for young people or the difficulty we had recruiting a sample of young people and their parents/carers who may have been further along in their recovery journey. Some parents who were invited refused to give consent for their child to take part in our research. Those that indicated a reason for this suggested they were concerned about prompting a relapse or causing unnecessary distress if the child was asked to talk about what was a difficult period. Perhaps this reservation in itself tells us that, even after symptomatic improvement, a sensitivity and fear of distress remains on the part of parents. However, as the parents were acting as gate-keepers we do not know if the children had the same reservations and fears.
Challenges and further work
These findings raise questions and challenges regarding the conceptualisation and implementation of recovery-focussed practice in mental health services for young people and their families. At present further exploratory work needs to be conducted with young people, their families and professionals in order to understand how recovery principles might best be implemented. In addition further data are required on the recovery measures to further explore their utility for care planning and evaluating recovery-focussed services. Furthermore, recruiting participants who are not in contact with statutory services would illuminate those for whom recovery is a spontaneous experience. We are looking for collaborators to extend this work. We welcome thoughts and suggestions from the recovery community: young people, their families, clinicians or researchers.
Alvord,M. K., & Grados, J. J. (2005). Enhancing resilience in children: A proactive approach. Professional Psychology: Research and Practice, 36(3), 238–245, http://dx.doi.org/10.1037/0735-7028.36.3.238
Department for Education and Skills (2003) Every Child Matters
Fonagy, P., Steele, M., Steele, H., Higgitt, A., & Target, M. (1994). The Emanuel Miller Memorial Lecture 1992. The theory and practice of resilience. Journal of Child Psychology and Psychiatry and Allied Disciplines, 35, 231–257
John, M., Jeffries, F., Acuna-Rivera, M., Warren, F., Simonds, L., (2014 in press) “Development of measures to assess personal recovery in young people treated in specialist mental health services” Clinical Psychology and Psychotherapy. DOI: 10.1002/cpp.1905
Scottish Government (2008) A guide to Getting it right for every child http://www.scotland.gov.uk/Resource/0042/00423979.pdf
Simonds, L. M, Pons, R. A., Stone, N. J. Warren, F., John, M (2013). Adolescents with Anxiety and Depression: Is Social Recovery Relevant? Clinical Psychology and Psychotherapy. DOI: 10.1002/cpp.1841
South London and Maudsley NHS Foundation Trust and South West London and St George’s Mental Health NHS Trust (2010) Recovery is for All, Hope, Agency and Opportunity in Psychiatry: A Position Statement by Consultant Psychiatrists
Zolkoski, S. M., Bullock, L. M. (2012) Resilience in children and youth: A review. Children and Youth Services Review 34 (2012) 2295–2303