Factors That Affect Early Exit from Adolescent Mental Health Treatment

In the 21^st century, we know a lot about mental health disorders.

We know far more now than we did, for instance, in the 1980s. Research that began in the 70s, continued though the 80s and 90s, and reached clinicians and patients in the early 2000s teaches us that mental health disorders are chronic medical conditions that respond well to evidence-based treatment. In most cases, treatment for mental health disorders includes psychotherapy, lifestyle changes, and medications, if necessary.

That’s almost identical to the treatment of other chronic medical conditions that are not related to mental health, such as diabetes, hypertension, or cancer. The only difference is the psychotherapy, which is best understood as treatment for thoughts and emotions, as opposed to treatment for the body.

The current approach is called the medical model of mental illness. It also applies to addiction. What the medical model teaches us is that mental health disorders and addiction disorders are not the result of character defects, poor decision-making, or moral flaws. They’re medical conditions that have a variety of genetic, environmental, and interpersonal causes. Perhaps more importantly, they’re medical conditions we know how to treat – just like we know how to treat diabetes, hypertension, and other diseases like cancer.

We know the first-line treatment almost all mental health disorders – for individuals who are not in crisis – is outpatient psychotherapy. For addiction, psychotherapy may come after initial detoxification and addiction counseling, but the template is the same. One-on-one outpatient therapy, or group therapy in an intensive outpatient (IOP) setting, is the first step. And in many cases, when combined with medication and lifestyle changes, it’s the core of healing and recovery.

Outpatient treatment works.

That’s clear.

But there’s a problem: too many teens drop out of treatment early.

This article examines why.

Teens, Mental Health, and Treatment: The Big Picture

It’s safe to say that any parent with an internet connection knows about the state of teen mental health in the United States in the post-pandemic era. Prevalence rates of just about every mental health disorder you care to name are on the rise. That means teens need effective outpatient treatment now more than ever. Whether they engage in traditional outpatient therapy, virtual outpatient therapy, or an intensive outpatient program for teens, the help they get now can improve – and possibly save – their lives.

Let’s back up for a moment and look at statistics that include both North America and Europe. In a paper called “A Meta-Analytic Review on Treatment Dropout In Child And Adolescent Outpatient Mental Health Care,” researchers report that:

• Around 7% children and adolescents have mental health disorders with impairment significant enough to receive a referral for outpatient treatment
• Only 2.5% of children and adolescents receive appropriate mental health care, such as:
  • Integrated treatment for alcohol and/or substance use disorder (AUD/SUD)
  • Psychotherapy for mood disorders such as depression (MDD)
  • Behavioral therapy for externalizing disorders such as attention-deficit hyperactivity disorder (ADHD)
• Of those who receive treatment, experts estimate that 28% –75% terminate psychotherapy prematurely.

Untreated mental illness can impair typical function during adolescence and lead to long-term problems throughout adulthood. The consequences of untreated mental health disorders, or undertreated mental health disorders, include:

During Adolescence

• Decreased academic performance
• Impaired brain development
• Disrupted social activity
• Relationship problems with friends, family, or romantic interest
• Alcohol or substance abuse
• Risky behavior
• Suicidal ideation
• Suicide attempts

During Adulthood

• Reliance on public health services during mental health crises
• Relationship problems: difficulty forming and keeping relationships
• Decreased academic achievement
• Decreased work performance
• Unemployment
• Homelessness
• Suicidal ideation
• Suicide attempts

Those are serious consequences. We’re confident every parent wants to protect their teenage children from experiencing anything on those lists. And they can help protect their teenage children by getting an accurate diagnosis and seeking office-based outpatient treatment, or treatment at an adolescent mental health center.

But there’s a caveat: teens need to stay in treatment to experience the full benefits of psychotherapy. We’ll discuss the reasons teens drop out of treatment in a moment. First, though, since we looked at big-picture statistics, we’ll share data specific to the U.S. – then we’ll look at why teens terminate treatment early with such alarming frequency.

Teen Mental Health: Demonstrated Need for Robust Outpatient Treatment

Data from the Centers for Disease Control (CDC), collected in 2018-2019, shows the following. Among adolescents age 12-17:

• 15.1% reported a major depressive episode.
• 36.7% reported constant feelings of sadness/hopelessness
• 4.1% met criteria for a substance use disorder (SUD)
• 1.6% met criteria for an alcohol use disorder (AUD)
• 3.2% met criteria for illicit drug use disorder
• 18.8% considered attempting suicide
• 715.% had a suicide plan
• 8.9% attempted suicide

That’s where our teens are right now, mental-health wise. They need support. And as we mention above, the first line of  treatment and support for mental health and addiction disorders is outpatient psychotherapy. Yet, despite the clear need for treatment, dropout rates are high: experts estimate that anywhere between 1/4^th and 3/4^th of teens who initiate outpatient treatment abandon treatment against or before the recommendation of their therapist, psychiatrist, or other supervising physician or clinician.

We examined data from several sources. We linked to one source above. Here are the other four sources we used to collect the information that follows:

• Reasons for Dropout of Clients from Therapy
• Factors Associated With Early Dropout From Adolescent Psychiatric Outpatient Treatment
• Substance abuse treatment drop-out from client and clinician perspectives
• Differences in Dropout between Diagnoses in Child and Adolescent Mental Health Services

If you like diving into research, we encourage you to review those sources. If not, we’ll summarize their conclusions now.

Early Exit from Outpatient Treatment: What Are The Causes?

We found two primary themes in the extensive information published in those articles. Based on the data, the two categories of reasons for dropping out of treatment are external factors and internal factors. External factors refer to circumstances that originate outside the individual in treatment, while internal factors refer to motivations that originate within the individual in treatment.

We’ll start with the external factors.

Treatment Dropout: External Factors

Family

Family participation in treatment for mental health or substance use disorders is one of the most important predictors of treatment adherence and treatment success. When a family is all on board and all-in for treatment, the teen in treatment has a greater chance of completing their course of treatment. On the other hand, when family does not participate in treatment, or when an influential family member questions the validity of treatment, it can change everything. Doubt, ridicule, and casting aspersions on the treatment process can cause a teen to abandon treatment, regardless of the negative consequences.

Friends

Close friends play a similar role to family in treatment adherence. For adolescents, peer approval is a big part of life. If a teen in treatment has friends who support them on their recovery journey, they have a greater chance of treatment adherence and treatment success. On the other hand, like in a family, an influential friend who questions or doubts or ridicules the treatment process can cause a teen to abandon treatment prematurely.

Time

In some cases, teens are unable to complete treatment because of time constraints. They may initiate treatment, but balk at staying in treatment for longer than a month or two. This can happen whether teens experience treatment progress or not. Teens and families may decide “that’s enough” and abandon treatment against the advice of clinicians.

Distance

This may be related to time, and it may not. It’s most often related to transportation issues, which are considered a significant barrier to treatment, especially for teens who live in rural areas. A family with limited resources, with two parents working full-time, simply may not have the resources to make the drive to therapy.

Money

Cost is often the elephant in the room. A family may believe treatment can work, want treatment for their teen, and live in an area where there are sufficient treatment options. However, if they’re uninsured, low-income, and public programs cannot make up the difference, they may not have the resources to commit to six months or more of weekly or twice weekly outpatient treatment. This can lead to teens participating in one or two outpatient session, then ceasing treatment.

Treatment Peers

In some cases, a teen in an IOP program, which incorporate group therapy as a standard treatment approach, may not get along with the other teens in the program. Friction, dislike, or other interpersonal issues can cause a teen to abandon treatment against the advice of clinicians.

Treatment Center Staff/Facility Rules and Regulations

In very few cases, teens cite problem with clinicians and staff at an adolescent treatment center as a reason for abandoning treatment. In even fewer cases, teens cite treatment center rules as reasons for abandoning treatment.

A quick note on family and friends: family and friends that believe treatment can work and understand and support the treatment process are protective factors that promote treatment adherence. This is an important piece of the puzzle to understand. Teens are influenced by the people they love and respect, and when those people support their treatment, their chances of treatment adherence and success increase.

Treatment Dropout: Internal Factors

Trust in Treatment

Teens who are don’t believe treatment can work or doubt the validity of the treatment process are likely to abandon treatment after one or two sessions. Education and awareness can help mitigate this phenomenon, but the teen has to arrive at their trust in the process themselves: trying to force it does not work.

Satisfaction With Treatment

Teens who think their treatment is working are more likely to adhere to treatment than teens who don’t. If they see progress, and think their treatment helps and is headed in the right direction, they’ll keep coming back. If they don’t see progress, they’re likely to be unsatisfied. Dissatisfaction is a significant predictor of early departure from treatment against the advice of clinicians.

Motivation

A teen who wants to change and ready to commit to change is more likely to adhere to treatment than a teen who’s lukewarm about treatment. This is true for teens with addiction disorders and mental health disorders. A teen with SUD who wants to quit using drugs is more likely to stay in treatment than one who doesn’t want to quit using drugs. Likewise, a teen with moderate depression who wants to learn to manage their symptoms is likely to adhere to treatment, whereas a teen with mild depression who doesn’t think they need treatment is unlikely to participate in more than one or two sessions, despite their awareness of the long-term effects of untreated depression.

Relationship With Therapist

A positive therapeutic relationship based on mutual trust and respect is at the core of any course of outpatient treatment. A teen who does not trust or respect their therapist will not want to return. In addition, if a teen senses their therapist does not trust or respect them, they’re also unlikely to return for additional sessions.

Stigma

We addressed the stigma attached to treatment as enacted by family members above. In some cases, teen internalize this stigma and think that because they have a mental health or addiction disorder, they’re bad, wrong, broken, damaged, or something else. These inward-directed emotions and judgments can be painful and difficult to escape. When a teen internalizes stigma to a significant degree, they may abandon treatment out of stigma-induce shame or embarrassment.

ADHD Diagnosis/Externalizing Disorder Diagnosis

Teens with ADHD or an externalizing disorder such as conduct disorder (CD) are more likely to abandon treatment prematurely than teens without a diagnosis of ADHD or another externalizing disorder. On the other hand, teens with a mood disorder such as major depressive disorder (MDD) are more likely to adhere to treatment.

Substance Use

A teen with a mental health disorder who uses alcohol or drugs is less likely to adhere to treatment than a teen that does not use alcohol or drugs.

Keeping Teens In Treatment: Diagnosis is Critical

There’s another factor here that we know from previous research on related topics plays a role in treatment adherence. An accurate diagnosis makes a difference. In our article Depression In Boys: Challenges in Diagnosis we discuss why clinicians may miss the presence of depression in boys, and instead diagnose an externalizing disorder like ADHD or conduct disorder.

In a nutshell, boys may express their depression as anger, irritability, or hostility. Then, when they enter outpatient treatment for an externalizing disorder that may appear appropriate for those symptoms, they may not make progress, because there’s a treatment mismatch. The techniques that help teens with externalizing disorders are not the same as those that help teens with internalizing disorders. When the family – and the teen – don’t see progress, they may abandon treatment.

In addition, a clinician may underestimate the severity of the disorder. Or, the teen may not be entirely forthcoming about the severity of their symptoms. In those cases, a clinician may diagnose a mild disorder when the disorder is moderate or severe. A mild disorder typically means outpatient treatment. But a teen with a severe disorder in outpatient treatment may be in the wrong place. They may not make any progress because of a level of care mismatch. That teen may need a partial hospitalization program (PHP) or a residential treatment program (RTC), where the treatment they receive matches the severity of the symptoms they experience.

In all cases, it’s important to maintain an open and honest dialogue with the treatment team. If a teen does not make progress in outpatient treatment, there’s a reason. With patience, trust in the process, and transparent communication, families, teens, and therapists can collaborate to discover the reason, make adjustments, and find a solution that leads to the best possible outcome for everyone involved.