Approximately 20% of youth are diagnosed with a mental health disorder and 14% of youth with a mental health disorder function with clinically significant impairment (Waddell, Offord, Shepherd, Hua, & McEwan, 2002). Comorbidity of mental health disorders is also common in adolescents (Pine, Cohen, Gurley, Brook, & Ma, 1998). Since the onset of approximately 50% of lifetime mental health disordelrs occurs by adolescence, it is crucial to further understanding of adolescent mental health disorders. Emotional and behavioral disorders (EBDs) are among the most prevalent mental health disorders in adolescents at 16.3% combined (Waddell & Shepherd, 2002). EBDs include internalizing disorders (e.g., depressive or anxiety disorders) and externalizing disorders (e.g., conduct disorder or attention-deficit hyperactivity disorder). Internalizing symptoms refer to how youth personally feel or think; externalizing symptoms pertain to how youth outwardly display themselves (Egger & Angold, 2006). It is important for adolescents with EBD to manage symptoms effectively since neurological processes related to higher cognitive functions often develop during adolescence (Yurgelun-Todd, 2007). The etiology of mental health disorders is multifaceted and includes biological, environmental, genetic, psychological and social factors; however, a poor family environment appears to be highly relevant to the development of EBDs. Family poverty, parental history of mental illness, family dissolution, poor adult-child bonding and negative parenting styles are significant risk factors for the development of EBD (Bornovalova, Hicks, Iacono, & McGue, 2010; Moffitt, 2005; Waddell, McEwan, Shepherd, Offord, & Hua, 2005). However, there is a dearth of research that is focused on the management experiences of youth with EBD.

Treatment options for adolescents with EBD vary from less intensive options (e.g., outpatient therapy or community-based services) to more intensive options (e.g., residential treatment or psychiatric inpatient care). Residential treatment (RT) is typically reserved for very troubled youth with moderate to severe EBD where less intrusive treatment is not an option. While there are other types of RT (e.g., RT for substance abuse), the focus of this study was on RT for the treatment of EBDs. RT provides a secure setting where youth reside to receive 24-h supervision and individualized mental health treatment. Treatment can be multidisciplinary including social workers, child youth workers, psychiatrists, and teachers. Youth typically stay in RT for approximately 7–9 months (Preyde et al., 2011b).

Outcome studies of RT have shown mixed results. From admission to discharge, statistically significant improvements in psychosocial functioning and symptom severity have been noted (Kapp, Rand, & Damman, 2015; Lyons, Woltman, Martinovich, & Hancock, 2009; Preyde, Frensch, Cameron, Hazineh, & Riosa, 2011a; Preyde et al., 2011b). However, many youth still function within the clinical range of psychosocial functioning and symptom severity, while some youth show no improvement or worsen. Some youth have maintained improvements at a 3-year follow up (Preyde et al., 2011b). Such variation in functioning may suggest difficulty in adaptation after RT. After discharge, youth need to adapt to the home, school and community while coping with symptoms of mental health disorder. One indicator of poor adaptation post-discharge is involvement with the law and Cameron, Frensch, Preyde, and Quosai (2011) reported a greater proportion of youth had contact with law enforcement at a 12–18 month follow up, compared to admission. Difficulties in community adaptation have also been cited approximately 6 years after discharge from RT (Grosset, Frensch, Cameron, & Preyde, 2017; Preyde et al., 2016). Factors such as family involvement of functional families during RT and family support after RT have been shown to relate to better adaptation in the long-term (Sunseri, 2004); however, youth appear to struggle to transition into home and community life after RT.

Generally, research seems to have been focused on outcomes or proxies of adaptation such as functional scores. A few studies have been focused on the experience of transitioning out of RT. Hess, Bjorklund, Preece, and Mulitalo (2012) focused on the transition experiences of youth and families considered successfully transitioned after RT. A need for parents to be confident, trust their children and show a willingness to change themselves during the transition was reported by participants (Hess et al., 2012). In this study, youth reported the need to develop and implement better coping strategies for challenges in life, have realistic or healthy expectations regarding mistakes or setbacks in symptoms, and understand that RT treatment was just the beginning of recovery. In a separate study, which included families who did and did not successfully transition, barriers to transition for adolescent girls 1 year post-RT included: returning to alcohol and substance use influences, negative boyfriends and unchanged family environments (Hess, Bjorklund, Preece, & Draper, 2013). These findings provided insight into factors to support the transition process, but the investigators were not focused specifically on lived experience. Thomson, Hirshberg, and Qiao (2011) reported inconsistent transition experiences 3 and 12 months post-RT. Some youth experienced a difficult adjustment at 12 months post-RT as they returned to previous behaviors; however, other youth appeared to struggle at 3 months post-RT due to a lack of structure in the home (Thomson et al., 2011). Further examination of the post-RT transition is needed. There seems to be a dearth of explorations of experiences in the immediate post-RT period and environment. The purpose of the current study was to explore the caregivers’ perspective on initial transition experiences and management approximately 4 weeks after youth were discharged from RT.

While there is limited research on this topic from any perspective, caregiver reports were chosen since youth with EBD may have inaccurate perceptions of their emotional adjustment or problem behavior (McCauley Ohannessian, Lerner, Lerner, & von Eye, 1995; Nijhof, Otten, & Vermaes, 2014). Further, the family context in research is important since youth may return to the family environment which contributed to the onset of their mental health disorder and it has been suggested that families take an active role during the transition after RT (Leichtman & Leichtman, 2001; Pumareiga, 2007). It is hoped that the findings from this study may inform transition support for youth leaving residential mental health treatment. The purpose of the study was to explore caregivers’ perspectives of their child’s initial transition home after discharge from RT using in-depth interviews to gather qualitative experiences.

Method

This report is part of an ongoing longitudinal project on youth adaptation following RT. Institutional ethics approval for the overall project was granted by the University of Guelph and participating agencies in Ontario, Canada. This report is focused on caregiver perceptions immediately following the discharge of their child to their home. Inclusion criteria were youth aged 12–18 years discharged from RT for EBD who intended to return to the care of their family, the caregiver the youth identified as appropriate to interview, ability to communicate in English and provide informed consent.

Participants were recruited from seven mental health agencies for youth covering a central region in south-western Ontario. Agency administrative staff asked permission from eligible youth and their families to provide contact information to the researchers. If permission was granted, researchers contacted the caregivers by phone to obtain informed consent and schedule an interview approximately 4 weeks after the youth’s discharge date. It was thought that 4 weeks (within about 30 days) after discharge would provide the families some time to adjust to the transitions and still be considered an immediate transition period. Moreover, following up after 30 days of discharge is a commonly used timeframe for people with mental illness (Feng, Toomey, Zaslavsky, Nakamura, & Schuster, 2017; Jackson, Shahsahebi, Wedlake, & BuDard, 2015). Additionally, conducting interviews within 1-month post-RT may allow some participants to retrieve episodic memories (Anderson, 1983; Tulving, 2002). Four trained graduate students in social work, and family relations and human development programs conducted in-depth, semi-structured, qualitative interviews with participants. Training included confidentiality and ethics tutorials, study protocol review, listening to an experienced interviewer, and practice sessions with other research assistants. Prior to beginning an interview, written consent was obtained and participants were reminded that the interview would be audio recorded. Participants received $40 as compensation for their participation. Interviews lasted approximately 1.5 h and were audio-recorded. They often took place in the home of the participant.

Interview Protocol

A questionnaire was used to capture demographic information and an interview guide was used to capture caregivers’ lived experiences. Field notes were taken by the interviewer to provide contextual information. Interviews were semi-structured; thus, the interview guide contained open-ended questions regarding youth and parents’ transition experiences. Three general sections were used: transition experiences, life domains and personal functioning. Questions about transition experiences were developed to explore how the youth and family functioned immediately after transition and at the time of interview (e.g., what was it like between you and your child at first?). Questions were developed to explore youth functioning along life domains of interest including school, work, family life, peers, community, hopes and dreams. Finally, questions about personal functioning and how youth managed difficulties were asked in terms of life domains (e.g., what does your child do when things are not going well with friends?) and emotional well-being (e.g., how is your child doing emotionally now?). The guide provided a general framework; however, participants were encouraged to speak openly about the youth’s transition and their experiences. Probing questions were used if clarification was needed.

Measures

Participants completed the parent version of the strengths and difficulties questionnaire (SDQ; Goodman, 1999) to provide understanding of youth psychological difficulties. The SDQ consists of five subscales: emotional problems, conduct problems, hyperactivity-inattention, peer problems and prosocial behaviour. Subscale scores range from 0 to 10 where higher scores indicate greater difficulty, except for prosocial behavior where higher scores suggest greater prosocial behaviour. The sum of subscale scores (excluding prosocial behaviour) indicates the total difficulties score which range from 0 to 40. Subscale scores can be categorized as average, or slightly raised, high or very high difficulties (Goodman, 1997). The subscales have demonstrated low to moderate internal consistency (αs ranging from 0.60 to 0.75); total difficulties scores appear reliable (α = 0 = 82; Goodman, Meltzer, & Bailey, 1998). The parent SDQ has been shown to have fairly good construct validity, correlate with other measures of clinical symptoms and have good inter-rater correlations (Becker, Woerner, Hasselhorn, Banaschewski, & Rothenberger, 2004; Goodman et al., 1998; Stone, Otten, Engels, Vermulst, & Janssens, 2010). Criterion validity has been demonstrated with strong significant (p < 0.001) correlations on all subscales with the child behavior checklist (CBCL; ranging from r = .59 to r = .87; Goodman & Scott, 1999) and retest stability after 4–6 months (mean r = .62) has been demonstrated (Goodman, 2001).

Data Analysis

Interviews (audio-recordings) were transcribed verbatim by three undergraduate research assistants and then the transcripts were uploaded into NVivo. Interview data were analyzed independently by the first two authors of this report. Subsequently, these two authors met with the Principal Investigator (last author) to review themes, discuss discrepancies and arrive at a consensus. Thematic analysis, as described by Braun and Clarke (2006), was used to analyze interview data. These six steps include becoming familiar with the data, generating initial codes, searching for themes, reviewing themes, defining themes and articulating themes. Themes represented prevalent information or salient information which answered the research question (Braun & Clarke, 2006). Since this study was exploratory, an inductive approach was used to allow for themes to be based on the data. Data were coded at the semantic level to provide surface meaning or explicit information (Braun & Clarke, 2006). Quantitative data (demographics and SDQ data) were entered into the Statistical Package for Social Sciences (SPSS). Descriptive statistics were used to analyze quantitative data.

Results

Caregivers were ten biological mothers, one step-mother and one biological father. Given this heterogeneity, only the biological mothers were included in this analysis. Characteristics of mothers and youth appear in Table 1. 50% of mothers were married or in common-law relationships. Data on salary range were reported by 8 mothers, and these incomes ranged widely from less than $30,000 to over $90,000. 60% of the youth were female. Results from the parent SDQ are provided in Table 2. Emotional problems and peer problems appeared to be the most problematic for youth in this sample.

Table 1 Sample characteristics (n = 10)
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Table 2 SDQ descriptive statistics (n = 10)
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Initial Transition

Seventy percent of mothers (n = 7) spoke about the need for some relationship rebuilding and conceptualized the initial transition period as a fresh start or new beginning in the mother-youth relationship. For example, one mother emphasized a renewal in the relationship with her child:

I don’t want to think of anything that happened before. I’m just going to think of how things are going to start and think of this as a brand-new start for us.

In addition, mothers (n = 8; 80%) reflected on themselves or the family unit during the transition. This self-reflection could have been reconceptualization of past events or re-evaluating the family unit since the youth’s return. A common re-evaluation pertained to setting realistic expectations of their child during the transition and in the future, as described by these mothers:

She had her moments but we expect they’re going to have moments, it’s not going to vanish.

Letting go of the expectation of what I always hoped for her and changing that to accept what is right now

This type of self-reflection appeared important for mothers to rebuild the relationships with their children after RT.

As mothers spoke about the initial transition, an adjustment period was apparent. For example, mothers noted a general awkwardness or strangeness within the family context. Additionally, variability in the level of mother engagement was evident. Some mothers spoke confidently about their child’s well-being or functioning in some life domains (often school). Other mothers provided minimal detail in their answers, often to questions about emotional functioning or peer relations. Nonetheless, 60% of mothers (n = 6) described some communication with their child in the form of negotiation, daily conversation or open-ended conversations.

Transitional Challenges

Caregivers reported that the transition home was challenging for the youth, the caregiver and their families. As expected, many mothers (n = 8; 80%) expressed an initial adjustment in the home during the transition, which may have required “a lot of stretching and juggling.” Mothers elaborated on the specific challenges they thought their child experienced. Four mothers (40%) stated that their child struggled to re-establish social networks. One mother acknowledged the difficulty in reforming social bonds:

I think it was just being away from [agency name]. I had to remind my common-law husband and [youth’s] brother that he was there for a long time… almost 10 months and he formed bonds with the people there and it’s like losing family.

Youth reportedly struggled to make friends, reconnect with old friends or missed former relationships at RT. Some mothers reported that their child resisted rekindling old friendships due to a fear of stigma. Additionally, three mothers (30%) stated that their child had difficulty adjusting to the reduction in environmental structure, as depicted in this mother’s comment:

She’s been struggling with that a lot… the difference between being in the insulated environment for six months and then the reality of, kind of, the world.

Mothers reported that youth enjoyed the structure provided at RT; one mother attempted to mimic the routine at RT to facilitate a smoother transition. These challenges were overwhelming, as evident in this mother’s narrative:

I think it was a bit overwhelming… detaching from where she was to back at home. I think she was a little uncertain about being able to manage. It was a bit overwhelming when she came home, like sensory overload. That took her a few weeks to kind of settle in and then finding her footing with a new daily structure. She would notice it’s really loud in here or turn the radio down in the car. She’s just like, ‘it’s too much’.

Transitional Supports

Mothers expressed a fear of losing support and beginning the transition with minimal support. The majority of mothers (n = 8; 80%) felt there was a lack of service support or that services provided were ineffective. This challenge was reported by many mothers, but it was also repeated throughout the interviews by many mothers. A need for more effective transition planning was evident in some mothers’ comments:

I wish that, ya know, there was a little bit more guidance… and maybe people with connections could have set something up right away, instead of being put on the 3-month waiting list.

At least a 7–10 day plan. Like ‘here’s your 7–10 day plan when he comes home, get that going and call us when you have that in place and we’ll write down the discharge date.’

Furthermore, five mothers (50%) explicitly stated that there was a lack of support from RT. These mothers reported feeling that RT did not follow up when promised and did not effectively connect the family to the required resources. One mother explained:

I mean the transition time, yeah, was very much okay, bye.

One mother also underscored how services tend to be focused on the child, rather than the parent or family.

Although mothers perceived a lack of support, different forms of support for youth and their families were described. Three mothers (30%) mentioned some support from RT, whether in the form of discharge preparation or post-RT support (e.g., weekly community groups). All mothers (100%) described themselves as a source of support for youth or attempted to provide support. Mothers reported making themselves available, providing advice or implementing strategies to support their child. For example, mothers may have helped with homework, drove their child to school or attempted to engage in daily conversation. Additionally, five mothers (50%) thought that youth sought support from their peers. These comments mainly pertained to peers known before admittance into RT.

Many mothers (n = 9; 90%) mentioned receiving some community support which was not RT- or family-related. These community supports often came from school, which included child and youth workers at alternative schools or teachers and principals who implemented individual education plans. Children’s Aid Society, community support groups and hospitals were also mentioned by some mothers as supportive networks that aided in the transition after RT. Two mothers (20%) attended caregiver support groups. Two mothers (20%) also reported receiving consistent community support: one youth had scheduled time with a social worker every week and one youth attended weekly dialectical behavioural therapy (DBT) sessions. Mothers who received weekly support for their child did not perceive a lack of service support.

Youth Transition Experiences

Mothers commented on how they perceived their child’s transition home. Commonly reported emotions the child displayed included: happiness (n = 7; 70%), nervousness (n = 6; 60%), emotional lability (n = 6; 60%) and feelings of being overwhelmed (n = 4; 40%). While youth appeared happy, mothers felt that youth were nervous about fitting into the home, school and peer circles. A few mothers thought youth were nervous about having to leave home again. Mothers also thought that youth quickly changed emotions, overreacted or misunderstood situations. For instance, one mother mentioned the uneasiness she felt at first around her daughter:

Well, at first it put me on eggs. Walking on eggs because I’d be worried about saying something because she’d jump down my throat, literally because I said something wrong.

Furthermore, feelings of being overwhelmed were apparent as youth may have seemed overly tired, overstimulated or unable to meet daily demands.

Understanding how mothers thought youth functioned in various life domains was also important. Many mothers (n = 5; 50%) felt youth were helpful around the home or appeared independent in some regard. For instance, youth may have been self-motivated to wake up for school and take their medications. Conversely, 40% of mothers (n = 4) reported their children to be dependent, especially in relation to personal health (e.g., taking medication or booking appointments) and school (e.g., needing homework help or being driven to school). The majority of mothers (n = 6; 60%) described a lack of self-esteem seen in youth which they thought often stemmed from poor school performance or peer relations. These mothers thought youth were critical of themselves and required constant reassurance throughout the transition. Furthermore, 50% of mothers (n = 5) felt their child lacked motivation. This lack of motivation was sometimes related to social interactions, but often in relation to school, as this mother explained:

I guess help her give her tools to cope with her schedule. She’s extremely capable of the work, it’s just more the motivational piece… maintaining the work ethic to finish.

An interesting concept explained by 40% of mothers (n = 4) was a “honeymoon period”, which described how common problems appeared absent in the beginning, but eventually resurfaced. For instance, initial school attendance was good but decreased over time or youth initially took care of themselves and then faltered. Youth also declined in emotional functioning such that they appeared more isolated and upset over time. Mothers noted that these shifts in functioning began to occur around 2 weeks post-RT.

Youth Transition Management

During the interview, mothers discussed their perceptions of youth transition management and functioning. All of the mothers (100%) described how engagement in some type of recreational activity appeared to help youth regulate their emotions. Creative activities such as writing, cooking, reading and painting were mentioned by 70% of mothers (n = 7). For instance, one mother felt that her daughter attended school regularly because she wanted to participate in her art class. Additionally, 60% of mothers (n = 6) commented on how youth used extracurricular activities (e.g., sports, video games, or exercise) to adjust during the transition. The use of activities for transition management was evident in this mother’s comment:

If she’s feeling things, then she’ll go through the list I guess. Listen to music, read a book, exercise, like she’ll go through all the steps that she has to if she has a thought in her head.

It is noteworthy that some youth reportedly sought extracurricular activities to manage their emotions, while other youth appeared to function well because of their extracurricular involvement. These creative and extracurricular activities were often available at school or easily accessible at home; only one youth was enrolled in an organized activity outside of school.

While engagement in activities appeared to be useful in transition management, mothers commented that at times youth were avoidant during the initial transition. Generally, youth seemed avoidant in terms of emotional (n = 7; 70%) and behavioral functioning (n = 7; 70%). 50% of youth (n = 5) appeared both emotionally and behaviorally avoidant. Youth were considered emotionally avoidant when mothers felt youth ignored talking about their emotions and the challenges they faced. For instance, youth would change the topic when asked about an emotional experience or refused to talk, as one mother explained:

I try to talk to her but once again, it’s, it’s hard because it’s only goes as far as she’ll share and, and, quite often, It’s just ‘I don’t want to talk about it.’

Youth were considered behaviourally avoidance when mothers youth physically removed themselves from stressful circumstances. For example, one mother noted:

She’s you know cranky or something, she stays in her bedroom... Just hides in her room, that’s about it. And I’m saying ‘why aren’t you coming down?’

It seems behavioral avoidance was used sometimes as a “break” to manage emotions, which permitted some youth to confront the stressful situation at a later time. However, for other youth, this type of avoidance coincided with lethargy (e.g., excessive sleeping). In a similar regard, 70% of mothers (n = 7) described how youth were avoidant of social experiences. Mothers reported that youth did not have friends nor had interest in making friends or rekindling old friendships. Minimal, if any, involvement in social or community groups was reported—even when it was readily available, as it was for this youth:

Yes um [worker] brought it up… she actually gave me a list of sports like even on a certain day like a Wednesday when he has half-day at school, he can join. Also at the library and stuff, he wasn’t interested. Even people at the boys’ house came over and wanted to take him… he wasn’t… but because of the situation I am in, I’m not going to fight with him, right?

When asked how youth managed challenges, some mothers mentioned the use of management strategies taught at RT. Four mothers (40%) mentioned “steps” or “tools” learned from RT that youth employed when dealing with challenges. Two of these mothers (20%) specifically cited the use of dialectical behavior therapy (DBT) during the transition. DBT is a type of cognitive therapy, often taught at RT, which helps youth identify harmful patterns of cognition and behaviour. One mother (10%) commented on how her son used some of the general coping strategies taught at RT, such as journaling or meditating. Finally, one mother (10%) simply stated that her daughter employed skills taught at RT, but did not specify the type of skills. From the mothers’ descriptions, it appeared that some RT-taught skills and knowledge were applied by youth during the initial transition after discharge.

Trustworthiness

In order to foster credibility of the data, member checking was completed. All mothers were sent a one page summary of results to their provided email address. Results were presented in an infographic which highlighted important findings related to youth transition experiences, parent transition experiences, youth coping strategies, and support networks. Two mothers (20%) responded: one mother corroborated the results and one mother stated that there should be greater emphasis on the lack of professional support.

Discussion

Insight into youth transitional experiences was provided by mothers who reported an initial honeymoon period where youth and mothers seemed to be making an effort in their relationship to get along and daily living seemed to be going relatively well. Some mothers also reported some awkwardness when the youth initially returned home. For many youth and caregivers, this initially calm period was followed by a decline in youth functioning. Mothers perceived that their children had some difficulty with transitioning after RT and navigating new ways of living and relating to one another. The narratives also underscored the significance of school- and peer-related issues. For instance, the perceived lack of self-esteem and motivation were said to be related to school performance or peer relations. Mothers also reported the re-establishment of social networks as a challenge for youth, although this finding is not surprising, since children with behavioral disorders can be more likely to be rejected by peers than youth without behavioral disorders (Dodge et al., 2003). Nonetheless, such comments were corroborated by SDQ results, which indicated that peer problems were highly problematic for this sample of youth. A similar variation in emotions (e.g., happiness and nervousness) and emotional lability were also described by mothers which was consistent with the high scores on the emotional problems subscale of SDQ.

In addition to describing transitional experiences, the purpose of this study was to foster understanding of how youth managed transition experiences or challenges. It is hoped that RT provided the skillset for youth to manage transition experiences. From a caregiver’s perspective, few youth appeared to have used RT-learned skills. Creative and extracurricular activities seemed to be useful management techniques for youth. These activities may have served as emotional outlets or forms of distraction. Some mothers felt that youth took pride in their creative work, which may have served to boost their self-esteem. Finally, these activities could have also provided a sense of structure, which youth seemed to desire. Although, it is uncertain how intentional youth were in their participation.

From the mothers’ descriptions, it appeared that youth did not actively manage transition experiences, but were rather passive. For example, passiveness was evident when many mothers described how youth socially isolated themselves to manage social pressures. Additionally, in being emotionally avoidant, it appeared that youth declined social support. Although, when some youth were behaviorally avoidant, they were only passive at first since they sometimes returned to deal with the stressor. Avoidance may have been how this sample of youth reacted to challenges. It is also noteworthy that the sum of emotional and peer problems scores on the SDQ indicated internalizing problems (Goodman, 1997) and this finding is remarkable since youth accessing RT are often characterized as displaying predominantly externalizing disorders, usually conduct disorder (Preyde et al., 2011b). Such information provided insight into the sample population, in the absence of clinical files. It may also explain why youth managed transition experiences in the form of avoidance or isolation.

In addition to youth transition experiences and management techniques, mothers were able to provide a caregiver’s perspective on the initial transition. The caregiver perspective permitted the understanding of family dynamics and relationships. While there was an initial adjustment in the home, there appeared to be communication and some relationship rebuilding. The theme of relationship rebuilding was emotionally salient in the mothers’ responses. As mothers spoke of the youth’s return as an opportunity for a fresh start, it is possible that the time youth spent at RT acted as a therapeutic separation. This idea was followed by what mothers considered a joyful reunion, which may also be related to the reported honeymoon period, as the reasons the youth were admitted to RT may have been overlooked. The relationship rebuilding seemed related to the caregiver reflection that was noted. A majority of mothers reflected on themselves after the youth’s return and may have realigned their expectations and perspectives during the process. This type of introspection was also described by the sample of parents in Hess et al. (2012) who recognized that continuous effort will be needed from parents. Pumariega (2007) emphasized the need for families to adjust to the child’s return and reinstate the youth’s role in the home—ideas which were discussed by mothers in the current sample. Caregiver reflection may be needed for parents to reflect on how it is not only youth who need to change—since they are sent away from home—but the family unit as well (Pumariega, 2007). The mothers’ comments aligned with a shift towards family involvement and relational practice in residential mental health treatment.

Movement towards refined residential mental health treatment also requires understanding of transitional challenges and support networks. Challenges for youth appeared related to social relations and adjustment to less environmental structure than was provided in RT. A pertinent challenge for mothers and families was the lack of service support. RT provided transition support for some of the families, while some mothers thought that RT did not follow through on support plans. It is possible that the lack of support was in part due to perception or an inability to use supports that are available. For instance, there may be a certain level of family functioning or resources needed to make use of supports. It is to be noted that mothers who reported weekly youth support (e.g., DBT sessions and community groups) did not perceive a lack of support. It may be that families required scheduled support during the transition, or in other words, a continuity of care. It is also possible that the discharge plans for some youth included support for caregivers while for other caregivers on-going support was not planned. Given the enduring nature of EBD, ongoing support after discharge from RT should be expected and planned. Overall, mothers’ comments indicated that youth and families were not managing the transition without a range of informal and formal supports. Therefore, ensuring a continuity of care is imperative.

Implications for Practice

The current findings elucidated some transition experiences which have implications for practice in residential mental health care. Not many youths reportedly used management skills learned at RT, but those youths who did seemed to noticeably benefit from their use. Service providers may identify the possible challenges and directly teach youth the types of skills that may be helpful. Specifically, based on the current findings, agencies may want to focus on self-esteem, social/peer relations and emotional problems. Furthermore, youth and families may want to be informed of potential declines in functioning around 2 weeks post-RT, and receive professional support specifically at this time. Lastly, RT centres may want to provide a continuity of care and emphasize connections to other community supports for families prior to discharge. This strategy could mean scheduling first appointments or transition planning months before the discharge date. Such practices could promote a continuity of care that could alleviate some worry for families and help equip them with the tool to manage a decline in youth functioning. Future research should include a focus on the effectiveness of services available after RT.

Relational practice in RT should also be promoted. Family involvement during any stage of RT has been emphasized in the field (Huefner, Pick, Smith, Stevens, & Mason, 2015; Miller, Christenson, Glunz, & Cobb, 2016) and is consistent with the Position Statement 44 of Mental Health America on RT, with respect to the items listed under Call to Action, ‘working with family members to increase their ability to manage the child’s behavior after his or her return to the home’ may be one area of focus for practice. Focusing on family relationships in RT may be beneficial during the transition, since mothers in the current study were attempting to reconceptualize their relationship with their child during transition. Additionally, incorporating parent supports is significant as only two mothers reported receiving caregiver support. The family environment to which youth return may have contributed to the onset of their mental health disorder (Leichtman & Leichtman, 2001). Attention to relational practice may also help youth establish a positive peer and social support network. Therefore, movement towards relational practice may be advantageous for youth and families.

Limitations

While this study makes important contributions to understanding the caregiver perspective of youth returning home, the study should be considered in light of its limitations. It is important to note that even though results suggested participants felt a lack of support from community resources, if and how the mothers actively sought support was not explored. As noted, the caregiver perspective was important to inform relational practice, but may not be representative of the youth perspective. Findings must be interpreted with caution as they represent mothers’ perceptions of youth functioning. This point may be particularly significant for those mothers who did not seem as engaged or knowledgeable about their child on certain life domains. Furthermore, when interpreting findings, it is important to consider the generally lower functioning in the families of youth with EBD. The impact of positive or negative family environments on youth transitioning home from RT was not explored in the study, but could be the focus of future research. Finally, the current sample included biological mothers; RT also serves troubled youth from the child welfare system who were not represented in the current study. Although unintentional, due to the absence of fathers in the sample, findings may not represent the opinions of fathers or other caregivers. Future research may be focused on any of the perspectives of the other caregivers, youth, and mental health service providers. Additionally, comparisons between caregiver and youth perspectives may be of interest.

The current study was based on seven agencies in south-western Ontario with relatively minimal variation in demographics. Findings may not be transferable to communities with varying ethnic groups; only two mothers in the study reported Aboriginal status. It may be beneficial to incorporate cultural factors into future research on the topic. Additionally, self-selection bias and the idiosyncratic nature of mental health disorder may limit the dependability and transferability of results.

Conclusion

In conclusion, the current findings advance understanding of youth transitioning after RT. Mothers reported an initial successful or peaceful reintegration of their child to the home environment after discharge from RT. However, mothers reported that their children experienced ongoing difficulties with managing emotions, peers, engaging with caregivers and school. This study highlights the need for on-going professional support for families and youth who accessed RT.