Supporting Families During Adolescents' Transition from Acute Psychiatric Care to Home and School Environment

Abstract

The transition from acute psychiatric hospitalization to home is a challenging period for adolescents and their families, with approximately one in four adolescents requiring readmission within a year (Edgcomb et al., 2020) and many facing difficulties maintaining outpatient treatment (Olfson et al., 2009). This period represents a critical juncture where support and preparation significantly influence recovery outcomes (James et al., 2010). This dissertation explored the lived experiences of caregivers in the southeastern United States navigating the transition of their adolescents from acute psychiatric hospitalization (≤ 3 weeks) to home and school environments to (a) identify gaps between institutional approaches and caregivers’ needs and (b) understand how caregivers make disclosure decisions and how these decisions impact access to community support.

Study 1 examined how health care and educational institutions support families during the transition using dyadic thematic analysis of caregiver couple interviews (N = 7 couples). Major themes identified revealed minimal coordination between systems, requiring caregivers to serve as primary intermediaries. Four major themes emerged: (a) released without resources or respect—“there was no roadmap”; (b) systemic gaps in support infrastructure—mismatch between what couples needed vs. what institutions provided; (c) couples filling the gaps—advocacy demands in fragmented systems; and (d) the institutional lottery with few winners. Caregivers consistently reported receiving limited transitional guidance while also expressing that they needed support in navigating the intersection of the health care and educational institutions and managing behavioral concerns in real-world settings. Cross-cutting findings showed an absence of disclosure guidance and that even well-resourced families felt unprepared for navigation challenges. These disconnects and gaps left caregivers navigating fragmented systems with inconsistent support.

Study 2 investigated caregivers’ disclosure decisions via interpretative phenomenological analysis of individual interviews with the same 14 caregivers. Multilevel analysis examined individual and couple-level patterns and identified a universal three-phase trajectory, with trajectories diverging based on early institutional encounters. During Phase 1 (0–3 months post-hospitalization), all couples maintained protective silence, describing intense shame and fear of judgment. Phase 2 (3–12 months) involved system-catalyzed transitions triggered by institutional requirements that required disclosure decisions. Phase 3 (1–3 years) revealed three divergent patterns: progressive disclosure among couples who encountered validating institutional responses, selective strategic disclosure among those with mixed experiences, and continued protective withdrawal among those facing repeated judgment or systemic failures. These patterns transcended socioeconomic status, affecting both highly resourced professional families and families with more limited resources.

Integration of findings revealed that institutional support gaps and nondisclosure may operate together to increase family isolation. By examining both institutional support and disclosure patterns, this dissertation conveys the nuanced and complex experiences of caregivers in the context of adolescent mental health transitions. Findings have implications for developing comprehensive discharge protocols with disclosure guidance, strengthening interinstitutional coordination, and implementing stigma-reduction initiatives to better support adolescents and caregivers during this vulnerable transition period.