Community-based Study of the Transition to Adulthood for Adolescents with Psychiatric Disorder

Ann Vander Stoep1, Shirley A. A. Beresford2, Noel S. Weiss2, Barbara McKnight3, Ana Mari Cauce4 and Patricia Cohen5

1 Department of Psychiatry, University of Washington, Seattle, WA.
2 Department of Epidemiology, University of Washington, Seattle, WA.
3 Department of Biostatistics, University of Washington, Seattle, WA.
4 Department of Psychology, University of Washington, Seattle, WA.
5 Division of Epidemiology, Columbia University, New York, NY.


    ABSTRACT
 TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 Study limitations
 REFERENCES
 
This longitudinal study examines the transition to adulthood in a randomly sampled, community-based cohort of adolescents. The study compares young adult outcomes of 33 adolescents with and 148 adolescents without psychiatric disorder. After adjustment for differences in age, gender, and social class, adolescents with psychiatric disorder were 13.74 times less likely to complete secondary school (95% confidence interval (CI): 4.17, 45.17), 4.07 times less likely to be employed or in college or trade school (95% CI: 1.4, 12.3), 3.13 times more likely to be involved in criminal activity (95% CI: 1.11, 8.87), and 6.46 times more likely to have gotten pregnant themselves or to have gotten someone else pregnant (95% CI: 1.75, 23.87). While adolescents with psychiatric disorder in this community-based study had outcomes that were somewhat more favorable than those of adolescents with psychiatric disorder in prior treatment-based studies, they nonetheless are at high risk of failing to meet young adult role expectations. Am J Epidemiol 2000;152:352–62.

adolescence; crime; education; employment; mental disorders; sex behavior; social support

Abbreviations: CI, confidence interval; CICS, Children in the Community Study; NACTS, National Adolescent and Child Treatment Study; NLTS, National Longitudinal Transition Study; RR, relative risk; SD, standard deviation; YAICS, Young Adults in Community Study


    INTRODUCTION
 TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 Study limitations
 REFERENCES
 
Each culture recognizes a time of passage from childhood to adulthood. The beginning of this passage is marked by the onset of the physical changes of puberty in early adolescence. The end is signaled by the acceptance of the responsibilities and privileges of early adulthood: completing school, finding work, developing a social network of friends and intimates, contributing to the maintenance and support of a household, and participating as a citizen in a community. Negotiating this period of life is challenging for most individuals. It is particularly difficult for youths with psychiatric disorder because the tasks that are central to successful transition often depend on the very abilities that are impaired (1Go).

The prevalence of psychiatric disorder in children has been estimated at 17–22 percent (2Go), and among adolescents nearing transition age, it may be higher than 30 percent (3Go, 4Go). Even applying the most conservative estimate to the general population of 17.6 million of those aged 18–22 years (5Go), there are more than 3 million transition-aged youths with a diagnosed or diagnosable psychiatric disorder currently living in the United States. The majority have never received mental health services (6Go).

For those who have been supported by child welfare, special education, juvenile justice, and/or children's mental health services, eligibility generally ends at age 18 years. Some child-serving systems, such as foster care and special education, have no adult counterparts. Although most mental health systems provide services to both children and adults, the criteria for eligibility change. The majority of children in public mental health systems have behavioral disorders, while entry into adult mental health systems requires diagnoses such as schizophrenia or bipolar disorder. Even if adult criteria were expanded, most available adult mental health services are geared to older persons with chronic impairment. Thus, developmentally appropriate supports may be less available just when they are most needed (7Go).

Three longitudinal studies documenting the transition to adulthood have been conducted with youths who were identified within service systems. The studies are the National Longitudinal Transition Study (NLTS) of 8,408 special-education students from secondary schools across the United States, 10 percent of whom were classified as Seriously Behaviorally Disturbed (8GoGoGo–11Go); the National Adolescent and Child Treatment Study (NACTS) of 812 youths with emotional disturbance, half of whom were from special education and half of whom were from residential treatment programs (12GoGo–14Go); and the McGraw Center Study of 86 adolescents with severe psychiatric impairment discharged from the first long-term residential treatment facility in Washington State (15GoGo–17Go). These three treatment-based studies have shown that during the transition period youths with psychiatric disorder are at high risk of dropping out of school, being arrested and unemployed, experiencing residential instability and homelessness, relying on public assistance, and lacking community supports.

Although they were groundbreaking in illustrating the plight of this population at a critical stage in their development, the NLTS, NACTS, and McGraw Center studies have several limitations. Without comparative information on outcomes of young adults without psychiatric disorder, it is hard to know the extent to which the difficulties encountered during the transition to adulthood among youths with psychiatric disorder differ from the norm. Comparing study outcomes with census data has provided evidence that youths with psychiatric disorder fare particularly poorly (7Go), but it is difficult to control such comparisons for social class and other demographic differences between youths with psychiatric disorder and the general population.

The definition of psychiatric disorder was not consistent across the three studies. The NLTS youths were classified as Seriously Behaviorally Disturbed according to the definition specified by the US Department of Education. The NACTS study subjects were considered Seriously Emotionally Disturbed by virtue of attending special-education classes for youths with serious emotional disturbance or of being placed in residential mental health facilities. The McGraw Center youths were diagnosed by Diagnostic and Statistical Manual of Mental Disorders, Third Edition criteria (18Go) as having a disturbed thought process or a marked, severe, or chronic affective disorder. They were severely incapacitated by their psychiatric disorder and were unable to function in a less restrictive community setting.

A further limitation of these studies was the selection of treatment-based, rather than community-based, samples of adolescents with psychiatric disorder. In the recent National Institutes of Mental Health Methods for the Epidemiology of Child and Adolescent Disorders study, fewer than one third of youths who had both a psychiatric disorder and significant impairment received specialist mental health services (6Go). Many factors, such as gender, ethnicity, rural/urban status, social class, and severity of illness, determine which children receive mental health treatment and which do not (19Go, 20Go). These selection factors hamper our ability to make inferences about the young adult status of children with psychiatric disorder in the general population on the basis of studies of children who have been treated by service systems. It could be argued that the young adult outcomes of adolescents with psychiatric disorder who have been treated are either likely to be poorer (due to selection into treatment of the most disturbed) or likely to be better (due to the positive effects of treatment) than the outcomes of adolescents with psychiatric disorder in the general population. These gaps in our understanding could be filled by community-based studies in which demographic differences are controlled, outcomes of adolescents with and those without psychiatric disorder are compared, and selection factors are minimized.


    MATERIALS AND METHODS
 TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 Study limitations
 REFERENCES
 
Study sample
The Young Adults in Community Study (YAICS) is part of the Children in Community Study (CICS) (21Go). The purpose of CICS was to document the developmental course of a group of children who were similar to the general US population in socioeconomic status, family structure, and urban/rural residence and to identify factors related to the onset and persistence of mental disorders in childhood and adolescence.

The study sample was selected in 1975 by using a four-stage sequential procedure to obtain a probability area sampling of representative families in Albany and Saratoga counties in upstate New York who had at least one child between ages 1 and 10 years. One child was randomly selected from each qualified household. Sampling methods are described fully by Kogan et al. (22Go). Completed interviews were obtained from 976 of the 1,141 qualified households, yielding an initial response of 86 percent. The first follow-up (wave 2) was carried out in 1983 when 74 percent of the original 976 households were reinterviewed (21Go). Five children had died, 10 were located in areas too distant or isolated for follow-up, and 96 families refused participation or had scheduling problems that precluded interviews within the required time span. The families who were lost to follow-up tended to have the youngest children (ages 1–4 years in 1975) and to live in areas of urban poverty. To replace the segment of the original sample that had been disproportionately lost to follow-up, the sample was supplemented with 54 additional families who had children in the youngest age range and who lived in urban poor neighborhoods. The same enumeration and sampling procedures were used as in 1975. With this supplement, the wave 2 study cohort was closely representative of children in the geographic areas sampled, as confirmed by comparison with the 1980 census (23Go). In the second follow-up (wave 3) conducted in 1985–1986, 96 percent of the families interviewed in 1983 were reinterviewed, as well as half of those who had been located but not interviewed. Thus, 736 families participated in the wave 2 interview, and 754 participated in the wave 3 interview of the CICS.

The transition to adulthood has been viewed as a protracted process encompassing the life span from ages 16 to 25 years (24Go). Societal custom, however, designates 18 years as the "age of emancipation." Thus, 18 years was chosen as the cutoff point in the definition of the young adult cohort. Participants in the YAICS were the 181 youths who had not yet reached age 18 years at the time of their wave 2 interview in 1983 and who were age 18 years or older at the time of their wave 3 interview in 1985–1986, an average of 2.5 years later. Thus, each study participant "crossed the threshold into young adulthood," i.e., turned age 18 years, sometime between the wave 2 and wave 3 interviews.

Data collection
In each follow-up wave, fully structured interviews lasting about 2 hours were administered separately, but simultaneously, by pairs of trained lay interviewers to children and mothers or mother surrogates in respondents' homes. Data quality was maintained through intensive training of all selected interviewers, use of training and field operation manuals, postinterview debriefing, and systematic accuracy checks on data gathered from a random sample of interviews. Detailed information was collected regarding demographic status; family characteristics; parent-child relationship; child-rearing practices; family environment; physical environment; child's social life and activities; and child's personality, temperament, attitude, values, and quality of life. Psychiatric diagnoses were ascertained by administration of parent and child versions of the Diagnostic Interview Schedule for Children (25Go, 26Go).

Exposure measure
The exposure of interest in this study was the presence of psychiatric disorder in adolescence. Presence of psychiatric disorder was defined by using a two-stage algorithm. Stage 1 involved meeting diagnostic criteria for at least one of the types of disorder described below on the basis of pooled symptom endorsements from both the mother and the child. Although specific types of psychiatric disorder were not the primary focus of this epidemiologic study, the classification of psychiatric disorder was based on children having a Diagnostic and Statistical Manual of Mental Disorders, Third Edition Axis I diagnosis of anxiety, depressive, disruptive, or substance abuse disorder in 1983. The anxiety disorder category included diagnoses of overanxious disorder, separation anxiety disorder, and social phobia. All children who met diagnostic criteria for depression met criteria for major depressive disorder. The disruptive disorder category included diagnoses of attention deficit hyperactivity disorder, oppositional defiant disorder, and conduct disorder. Substance abuse included alcohol, marijuana, and/or other drug abuse. Sixty-nine (38 percent) of the sample met this stage 1 criterion.

In stage 2, for each of the diagnostic categories, an index was constructed to determine certainty of diagnosis. To construct the index, all symptoms, signs, and severity items, as reported by the child and/or the mother, were pooled and counted. The distribution of the index was estimated for the entire sample to determine the cutpoint of two standard deviations (SD) above the mean. A child who met diagnostic criteria in stage 1 and whose index score was two or more SD above the population norm in stage 2 was classified as having a psychiatric disorder (27Go). As a natural consequence of this scheme, those who did not meet both of these criteria were classified as having no psychiatric disorder.

The use of this two-stage algorithm yields a low probability of falsely classifying children who have no psychiatric disorder as having a disorder. This was desirable since the concern of this study was with youths who had the most severe mental health problems. An alternative classification system was considered that involved separating out an intermediate group who met diagnostic criteria and whose index score was between 1 and 2 SD from the population mean. Exploratory analyses, however, showed that this group was quite similar in young adult outcomes to the group that did not meet any diagnostic criteria. Thus, for a number of reasons, the more stringent definition of psychiatric disorder was used in this study.

The validity of the two-stage algorithm for classification of psychiatric disorder used in the CICS has been demonstrated in several studies that have shown prevalence estimates resulting from their application to be consistent with estimates from other studies and estimates of prevalence for specific disorders in age and gender subgroups to behave according to expected patterns. Childhood diagnoses established by these methods have shown strong correlations to known prenatal, perinatal, and familial risk factors for disorder measured prior to diagnosis, to functional status measured concurrently, as well as to known sequella of disorder (28Go).

As shown in table 1, 33 (18.2 percent) of the adolescents sampled met study criteria for psychiatric disorder. This prevalence estimate is comparable with prevalence estimates of psychiatric disorder from other community-based studies of children and adolescents (2Go, 29Go). Twenty-one (11.6 percent) met criteria for a disruptive disorder, 14 (7.7 percent) for a substance abuse disorder, 11 (6.1 percent) for an anxiety disorder, and eight (4.4 percent) for a depressive disorder. Seventeen youths met criteria for more than one type of disorder.


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TABLE 1. Exposure status of Young Adults in Community Study subjects

 
Outcome measures
The study outcome measures are indicators of young adult functional status. Measures are either cumulative, reflecting events occurring within the follow-up interval (e.g., criminal involvement), or static, reflecting the subject's status at follow-up (e.g., current employment). Follow-up interval pertains to the period between waves 2 and 3, and follow-up refers to the time of the wave 3 interview. Unless otherwise specified, all measures were from self-report by the young adult. All outcome measures were classified dichotomously except the two factors in the social support domain and the two scales in the employment status domain: work satisfaction and adequacy of income. These were ordinal measures. The five domains of young adult status are described below.

The secondary school completion outcome reflects whether a youth had completed or was on target to complete the 12th grade (no older than age 18 years and in the 12th grade) at follow-up.

The gainful activity outcome is a composite measure. Persons were classified as gainfully active if they were either engaged in full- or part-time employment or were attending college or other postsecondary school or both at follow-up, while persons were classified as inactive if they were neither employed nor in school. Also examined in this domain was a work satisfaction scale.

The criminal involvement domain includes information about whether the young adult, by either self- or parent report, had been in trouble with police within 2 years prior to the follow-up interview. The criminal involvement questions were framed in such a way that they could only be classified dichotomously. Specific types of antisocial activities were also examined, including getting into physical fights, damaging property, stealing from stores, stealing from other places away from home, threatening with a weapon, breaking and entering, and attacking others. Youths were classified as positive for specific types of antisocial activities if they were reported to have engaged in the activities, whether or not they had been in trouble with police.

The sexual activity domain includes sexual activity status at follow-up and the number of pregnancies to date. The pregnancy question was phrased, "Have you ever been pregnant or gotten someone pregnant?"

The single dichotomous measure within the social support domain was living alone at follow-up. In addition, principal component analyses were used to create factors from four scales reflecting various aspects of social support. The scales that were included in these analyses included "time spent with friends," parent-reported "social isolation," "quality of friendships," and "mate commitment." Details of the construction of these scales may be found in the paper by Cohen and Velez (30Go). Two factors, which reflected social integration and quality of interpersonal relationships, were used as outcome measures.

Classification of potential confounding factors
Age, gender, social class, and level of intelligence were examined as potential contributors to differences in young adult outcomes between adolescents with and those without psychiatric disorder. Because the age range of subjects in this study was narrow and because the rate of human development can be accelerated during the transition period, the impact of both linear and quadratic age variables was examined. The social class scale was constructed on the basis of mother's education, father's education, family income, and father's occupation. Intelligence was measured using the Ammons and Ammons Quick Test (31Go).

Statistical analyses
For each dichotomous outcome, relative risks and 95 percent confidence intervals were calculated, comparing youths who had a psychiatric disorder with those who did not (baseline group). Logistic regression models were fit to examine the age-, gender-, and social class-adjusted effects of psychiatric disorder (32Go). For the scaled outcomes, multiple regression models were fit to examine the age-, gender-, and social class-adjusted effects of exposure. Delta betas were plotted to assess the influence of individual observations on regression coefficients (33Go).


    RESULTS
 TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 Study limitations
 REFERENCES
 
The sociodemographic characteristics of adolescents with and those without psychiatric disorder are illustrated in table 2. Both groups had a fairly even gender distribution and a similar median age of just over 19 years. The proportion of youths from ethnic minority backgrounds was very low (5–6 percent) in both groups. About half of the adolescents without psychiatric disorder had Roman Catholic religious affiliation compared with two thirds of the youths with psychiatric disorder. The average family income was substantially lower in the group with psychiatric disorder ($18,000) compared with the group without psychiatric disorder ($21,000), and the proportion of mothers with more than 12 years of education followed a similar pattern (36 vs. 45 percent). Measured intelligence, however, was similar for youths with and those without psychiatric disorder.


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TABLE 2. Sociodemographic characteristics of adolescents with and those without psychiatric disorder, Young Adults in Community Study

 
The proportion of families who reported that they sought help for their children's emotional problems was nearly identical for youths with and those without psychiatric disorder. Of those with psychiatric disorder, 6.1 percent had received mental health consultation or treatment one or more times during the year prior to the wave 3 interview compared with 6.8 percent of the children with no psychiatric disorder.

Table 3 compares young adult outcomes of persons who had a psychiatric disorder in adolescence with those who did not. Adolescents with psychiatric disorder had significantly poorer outcomes across most domains of functioning.


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TABLE 3. Young adult outcomes of adolescents with a psychiatric disorder relative to other adolescents, Young Adults in Community Study

 
Completing secondary school
A total of 39.4 percent of adolescents with psychiatric disorder had not completed (or were not on target to complete) secondary school, making them over six times less likely than other youths to hurdle this major developmental milestone (relative risk (RR) 5 6.17, 95 percent confidence interval (CI): 2.88, 13.21).

Gainful activity
Young adults with a history of psychiatric disorder were nearly three and a half times less likely to be engaged in a "gainful activity" (RR = 3.45, 95 percent CI: 1.48, 8.04). Among young adults who were employed, those with psychiatric disorder reported less satisfaction with their work (adjusted t = 2.44, df = 109, p < 0.02).

Criminal involvement
Nearly one quarter of those who had a psychiatric disorder in adolescence had criminal involvement within 2 years prior to the follow-up interview. This was more than twice the proportion for those without a psychiatric disorder (RR = 2.24, 95 percent CI: 1.05, 4.80). The greatest discrepancies between young adults with and those without psychiatric disorder were evident for stealing from a school or another place away from home, but not from a store (27.3 vs. 8.1 percent) and for breaking into buildings (9.1 vs. 0 percent). In addition to these crimes, a significantly higher proportion of the young adults with psychiatric disorder reported damaging property, stealing from persons, breaking in, and attacking others. Differences between groups for stealing from a store and threatening with a weapon were negligible.

Sexual activity
Current sexual activity did not vary appreciably between groups (RR = 0.90, 95 percent CI: 0.64, 1.25), with 60–70 percent of each group reporting involvement. However, 28.6 percent of young adults with a psychiatric disorder reported having been pregnant or having gotten someone pregnant compared with fewer than 10 percent of those without a psychiatric disorder (RR = 3.21, 95 percent CI: 1.36, 7.54). Although pregnancy in young adulthood would not necessarily be regarded as a "negative" outcome, a higher proportion of young adults with psychiatric disorder reported feeling sad or terrible about their pregnancies.

Social support
No measure of social support revealed a statistically significant difference between exposure groups. However, young adults with psychiatric disorder were more likely to live alone (RR = 8.39, 95 percent CI: 0.79, 88.94). Neither the degree of social integration nor the quality of interpersonal relationships differed appreciably between exposure groups (data not shown). Over 90 percent of both groups reported having one or more friends to whom they could talk about anything, who would stick up for them, to whom they could turn for advice, and who really understood them.

For the dichotomous and scaled outcomes, estimates from the unadjusted analyses did not change appreciably after the effects of age, gender, social class, and intelligence were taken into account. For school completion, gainful activity, criminal involvement, living alone, and pregnancy, where fewer than 10 percent of the young adults without psychiatric disorder had "negative outcomes," the adjusted odds ratios shown in table 3 are roughly interpretable as relative risks (34Go). In carrying out regression diagnostics, the removal of even the most influential of the individual observations had little effect on regression coefficients.


    DISCUSSION
 TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 Study limitations
 REFERENCES
 
Through longitudinal tracking of children in a random sample of households, the YAICS has demonstrated that, relative to their peers, adolescents with psychiatric disorder are at elevated risk of failing to complete secondary school, being uninvolved in any gainful activity, getting into trouble with the police, and experiencing pregnancies. The effects of psychiatric disorder that had been demonstrated in prior treatment-based studies by no means disappeared once the natural course of adolescent development, selection factors, and potential confounders were taken into account.

Studies have shown differences in severity of psychopathology and impairment between youths who are treated in inpatient facilities and those who receive community-based (20Go, 35Go) or school-based (14Go) services. Table 4 displays outcomes from the YAICS and the three treatment-based transition studies arranged in order of average severity of psychiatric impairment of youths within the study cohorts. In the second column are results from the McGraw Center study, whose subjects were all severely incapacitated by thought and affective disorders and were living in a psychiatric residential treatment facility. The third column displays the results of the NACTS Study, in which half of the study sample were youths in residential treatment and half were in a less restrictive special education setting. The subjects from the NLTS, who are represented in the fourth column, were all selected from special education classrooms. The last four columns portray three subgroups of the YAICS subjects who were selected from a random sample of households in the community and census data from the US population in which nearly 20 percent have a psychiatric disorder. Of the YAICS cohort, 18 percent met criteria for a psychiatric disorder, and an additional 15 percent were classified for the purposes of this table as an intermediate group on the basis of having met the stage 1 criteria and having stage 2 index scores that were between one to two SD above the population mean. The YAICS subjects without psychiatric disorder comprise the "least impaired" group.


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TABLE 4. Comparison of young adult outcomes across transition studies, Young Adults in Community Study

 
Before conclusions are drawn, other methodological differences between studies must be taken into account. In addition to differences in the degree of impairment, variations in the demographic makeup of the study groups could have contributed to differences in outcomes across studies. For example, the age ranges of subjects varied. The proportion of young adults working, in school, or living alone would be expected to differ in groups consisting of mostly of those aged 18 years and those consisting of mostly of those aged 22. Setting aside other differences in study methods, young adult outcomes of the adolescents with psychiatric disorder in the YAICS generally lie between the more undesirable outcomes of the adolescents in the treatment-based studies and the more favorable outcomes of adolescents in the general population or YAICS adolescents without disorder. For most of the outcomes, there was a detectable reverse gradient of success that parallels the gradient in degree of impairment across the cohorts or populations studied. An exception was that, as mentioned in Materials and Methods, most of the young adult outcomes of adolescents in the YAICS "intermediate psychiatric disorder" group corresponded most closely to the outcomes of the adolescents in the "without psychiatric disorder" group.

The proportion of adolescents who completed secondary school increased as the severity of psychiatric impairment in the study cohort decreased. Among the adolescents in the YAICS with no psychiatric disorder, 93 percent graduated from high school. At the other end of the severity spectrum, only 23 percent of the young adults discharged from Washington State's only psychiatric residential treatment program completed secondary school. Employment in young adulthood followed a similar pattern, ranging from 46 percent of the McGraw Study cohort employed to 80 percent of those without psychiatric impairment in the YAICS cohort employed.

Among youths with psychiatric disorder in the YAICS cohort, the proportion with criminal involvement was somewhat higher than expected (25Go). However, the measures of criminal involvement were not comparable across studies. The YAICS assessed trouble with the police from report by either parent or youths, and the treatment-based studies measured actual arrests from a single reporter. Studies using single reporters will always yield lower estimates of criminal involvement compared with those that use multiple sources of information. Studies assessing any illegal behavior will yield a higher incidence of criminal involvement compared with those assessing trouble with police, arrest, conviction, or incarceration (36Go). For example, in the YAICS, when only parent-reported trouble with police was considered, the overall proportion with criminal involvement decreased from 16 to 9.5 percent. When the classification of criminal activity was widened to include both trouble with the police and behavior that would have invoked sanctions had the police known, the overall proportion rose to 40 percent.

The discrepancy in criminal activity between youths with and those without psychiatric disorder narrowed when the definition was broadened to include any illegal acts (age-, gender-, and social class-adjusted odds ratio = 1.50, 95 percent CI: 0.68, 3.32). This finding is consistent with evidence from other studies showing that the harsher the sanction, the wider the gap between adolescents with psychiatric disorder and other adolescents. In a recent investigation in Washington State, the age- and gender-adjusted arrest rate for youths with psychiatric disorder was three times higher than in the general youth population, while the conviction rate was six times higher (37Go).

Becoming pregnant was a common occurrence across cohorts of young adult women with psychiatric disorder relative to young adult women in the general population. In 1985 in the United States, 17 percent of women who were age 18 or 19 years became pregnant (38Go) compared with 29 percent of transition-aged women with psychiatric disorder in the YAICS. The limited evidence available from the McGraw Study and the YAICS indicates that persons with psychiatric impairment are more likely to experience multiple pregnancies at a young age and to lose custody of their babies (7Go).

In the YAICS, a relatively large proportion of adolescents with psychiatric disorder lived alone at the time of the young adult interview. Small numbers precluded the ability to draw a firm conclusion based on these data. However, this finding was consistent with the McGraw Study, in which a much larger proportion (22 percent) of the cohort of severely impaired young adults lived alone compared with persons in a slightly older age range from the general population (8 percent) (17Go). Meeting the financial and other life-skills demands is more challenging for young adults with psychiatric disorder, particularly when they face these challenges alone.

In the YAICS, differences between young adults with and those without psychiatric disorder on measures of social support were negligible. The NLTS suggested that although youths with emotional disabilities were quite active in informal networks with family and friends, they were less involved in society at large and were the least likely among all disability groups to belong to social or community organizations or to be registered to vote (10Go). Other studies have shown older adolescents with psychiatric disorder to have weaker social networks than their age mates (39Go, 40Go). Riley et al. (41Go) found adolescents, particularly males, who had disruptive disorders to be significantly poorer in a number of aspects of social functioning, including peer relationships, communication, and maintenance of supportive relationships.

Nearly all of the young adults in the YAICS cohort, including those with psychiatric disorder, reported having at least one close friend. Yet, considerable subjectivity may enter into a young person's assessment of the number and quality of their friendships. How young adults perceive their friendships may be different from how others would perceive them, and the perceptions of young adults with psychiatric disorder regarding the nature of their friendships may be more or less distorted than the perceptions of young adults without psychiatric disorder. Thus, it is possible that actual differences in the strength of social support networks were not detected through the methods used in this study.

One of the lingering questions remaining from prior studies was how much of the adversity experienced by children with psychiatric disorder could be attributed to the effects of social class. In this community-based study, low social class did not explain the adverse outcomes among adolescents with psychiatric disorder. Lack of confounding by social class is surprising since a consistent finding over the past several centuries has been that there is a higher prevalence of psychiatric disorder in lower social strata (42Go), and social class is also related to school completion, criminal involvement, employment, residential stability, and social support (43Go). Our results showed both social class and psychiatric disorder to exert strong independent effects on young adult outcomes.


    Study limitations
 TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 Study limitations
 REFERENCES
 
In general, study findings were plausible and consistent when examined in various ways within the study. However, the YAICS has a number of limitations. The validity of the classification of psychiatric disorder, as previously discussed, was state of the art in an art that has yet to be mastered. The classification of school completion was vulnerable to error insofar as some of those aged 18 years who had not completed the 11th or 12th grade by the time of the wave 3 interview may have eventually graduated, and some of the young adults who were in the 12th grade at the time of the wave 3 interview may not have graduated. Data available from the CICS wave 4 interview in 1990 indicate that both of these types of misclassification were minimal.

The YAICS included two wide follow-up windows within a fairly brief span of time, such that relaxing restrictions by including all subjects who were age 18 years or older at wave 3 would have resulted in a considerable blurring of age distinctions between the wave 2 and wave 3 interviews. Restricting the transition study sample to persons who were not yet age 18 years at baseline and who were older than age 18 at follow-up, while eliminating any overlapping ages in the wave 2 and wave 3 interviews, compromised the power of the study. Small numbers hamper the ability of the YAICS to draw firm conclusions about the magnitude of the effects of exposure. The confidence intervals around the estimates of relative risk were generally wide. The knowledge that adolescents with psychiatric disorder are three or 13 times less likely to graduate from high school will elicit public concern. Knowing that they are five or 400 percent more likely to commit crimes in young adulthood, however, would have different implications for rallying public action.

Attrition occurred between the original sample that was randomly selected and the cohort actually interviewed in waves 2 and 3. Of the original 1,141 children who were randomly selected in 1975, 190 were between ages 8 and 10 years. In this subgroup at the older age range of the original sample, 20 percent attrition occurred between waves 1 and 2, and 3 percent attrition occurred between waves 2 and 3. Unfortunately, there is no diagnostic information on the subjects who were lost to follow-up by wave 2, so that the occurrence of differential loss on the basis of exposure could not be assessed. There is, however, limited demographic information available that shows that the families lost to follow-up tended to have lower social class status, as was true in the overall study sample. Differential loss of persons in the lower social strata may mean that a higher proportion of those lost had psychiatric disorder. It is unknown whether losses to follow-up among those with a disorder were differential with regard to young adult outcomes. If they were and if the study was tending to lose adolescents with disorder who dropped out of school or committed crimes, then the YAICS associations appear weaker than they actually are.

A goal of this study was to examine a number of different facets of young adult adjustment to determine whether adolescents with psychiatric disorder were failing to meet only selected, or most, expectations. A pitfall of this approach was that in examining multiple outcomes, nearly 20 significance tests were carried out. When a Bonferroni correction (44Go) was applied to the four primary study outcomes based on the Wald test statistics from their association with psychiatric disorder in logistic regression analyses, the actual p values were so small that the corrected alpha level remained constant at 0.95. Accounting for half of the statistical tests were the adjusted multiple regression analyses that followed the original univariate tests. In the one circumstance (social support) in which, contrary to results from prior studies, outcomes for adolescents with and those without psychiatric disorder were quite similar, the similarity remained in the face of further in-depth scrutiny.

A related issue involves the lack of independence among primary outcome measures. Four strategies were used to examine the interrelations among secondary school completion, gainful activity, criminal involvement, and pregnancy:

  1. Odds ratios were calculated to assess the strength of association between individual outcomes;
  2. A factor analysis was performed;
  3. An index ranging from 0 to 4 was created for each subject by counting the number of negative outcomes, and the index was used to compare adolescents with and those without psychiatric disorder;
  4. Logistic regression analyses were conducted to examine the effect of psychiatric disorder on gainful activity, criminal involvement, and pregnancy above and beyond the effect of secondary school completion.

The first two strategies showed secondary school completion and gainful activity to be strongly related. Both had a moderately strong relation to pregnancy. Criminal activity was not strongly related to any of the other outcomes. The third strategy showed that the adolescents with psychiatric disorder were fairly evenly distributed across categories of 0, 1, 2, and 3 negative outcomes, whereas 70 percent of adolescents without psychiatric disorder had zero negative outcomes, while only 8 percent had two or three negative outcomes (table 5). This analysis demonstrated that the outcomes investigated were somewhat independent.


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TABLE 5. Comparison of the number of negative young adult outcomes for adolescents with and those without a psychiatric disorder, Young Adults in Community Study

 
The fourth strategy showed that secondary school completion explained part, but not all, of the association of psychiatric disorder with the other young adult outcomes. Addition of school completion to the logistic models moved the estimates of association (odds ratios) between psychiatric disorder and other outcomes toward the null. However, they continued to reflect strong associations (odds ratio 5 6.39 for pregnancy, 3.13 for police involvement, and 2.40 for gainful activity).

The question arises about how widely the results from the YAICS can be generalized. The interviews on which the YAICS are based were carried out more than a decade ago, prior to a number of reforms that may have reduced system-based supports for young adults with mental illness, such that discrepancies in adjustment between persons with and those without psychiatric disorder may have widened (45Go). More limiting may be the geographic location where the study was conducted and the demographic composition of the study population. Although the socioeconomic distribution of the study sample has been shown to be closely representative of the US population in the mid-1980s (23Go), it is likely that different results would emerge were the study methods to be applied in groups of children from different ethnic and cultural backgrounds.

For example, a study of the risk of arrests among children with mental illness in King County, Washington, found that mental illness had less of an effect on the already very high risk of arrest among African-American youths than it did on Caucasian, Hispanic, and Native-American children (37Go). Risk of dropping out of school is particularly high for African-American and Hispanic youths (46Go). Psychiatric disorder may have a negligible effect on failing to complete school for children in ethnic groups who are already at high risk of dropping out.

A clear understanding of why adolescents with psychiatric disorder fail would enable us to design more relevant supports. However, specifying causal pathways to poor young adult functioning is difficult to achieve in a small epidemiologic study that begins with late adolescent psychiatric disorder and ends with broad social outcomes in very early adulthood. Further investigation of employment and educational experiences, criminal behavior, social connections, and reproductive behavior for specific diagnostic subgroups is warranted. Vocational supports could be strengthened with a more thorough understanding of the employment patterns of young adults with psychiatric disorder, including the types of jobs they hold. Crime prevention would be enhanced if the particular circumstances in which such young adults break the law and get into trouble with police were known. Multiple perspectives could be sought to better understand the nature of the social support networks of young adults with psychiatric disorder. To paint a fuller picture, future studies should contain more pointed questions, as well as more frequent interviews across a greater life span. Larger study samples will yield more concise risk estimates, as well as greater ability to test causal hypotheses.

Prior treatment-based studies of cohorts of adolescents with psychiatric disorder had indicated that these adolescents were at high risk of poor young adult outcomes. The YAICS showed in a random sample of adolescents that those diagnosed with psychiatric disorder were at significantly higher risk than were other adolescents from their same communities and social status of failing to complete secondary school, being neither in school nor employed, engaging in criminal involvement, and becoming pregnant.

Many older adolescents with psychiatric disorder desire help during transition. In a prior analysis of the CICS data, youths with psychiatric disorder who were aged 17–21 years were significantly less likely to be receiving services and significantly more likely to want them than were youths who were under age 17 years (19Go). Of those young adults in the NACTS study who were not receiving mental health or vocational counseling, nearly a third reported that they wanted such help (14Go). The good news is that major strides have recently been made in the development of policies (47Go), principles (48Go), and programs (24Go, 49Go) designed to support youths with psychiatric disorder during the transition phase. The unfortunate news is that within our communities, implementation of these policies, principles, and programs has been very limited. It is time to implement the currently available repertoire of ideas to form a sturdy bridge to support the many adolescents in our communities with psychiatric disorder as they make the challenging transition to adulthood.


    ACKNOWLEDGMENTS
 
Funded in part by a Gatzert Child Welfare Fellowship.

The authors thank Drs. Stephanie Kasen, Christina Hoven, and Rob Moore from the Division of Epidemiology at Columbia University for their advisory role during the design and implementation of this study.


    NOTES
 
Reprint requests to Dr. Ann Vander Stoep, University of Washington Department of Psychiatry, Division of Child and Adolescent Psychiatry, Children's Hospital and Medical Center, Mail Stop: CH-13, 4800 Sand Point Way NE, Seattle, WA 98105.


    REFERENCES
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 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 Study limitations
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Received for publication September 11, 1998. Accepted for publication October 28, 1999.