Unheard Voices: Non –service using mothers perceptions of ......Unheard Voices: Non –service using mothersperceptions of their adolescents’ social and emotional wellbeing. Page

UnheardVoices:Non–serviceusingmothersperceptionsoftheiradolescents’socialandemotionalwellbeing 

LaurenVaughanOccupationalTherapist

YouthMentalHealthProjectOfficerManningMentalHealth

HunterNewEnglandLocalHealthDistrictlauren.vaughan@hnehealth.nsw.gov.au

September2014

FinalReport:RuralResearchCapacityBuildingProject(2012Intake)HealthEducationandTrainingInstitute(HETI)–RuralDivision

U n h e a r d V o i c e s : N o n – s e r v i c e u s i n g m o t h e r s p e r c e p t i o n s o f t h e i r a d o l e s c e n t s ’ s o c i a l a n d e m o t i o n a l w e l l b e i n g .

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Acknowledgements AhugesincereTHANKYOUtotheparentswhovolunteeredtobepartofmyresearchstudy,withoutyounoneofthiswouldhavebeenpossible.TotheHealthEducationandTrainingInstitute(HETI)IcannotthankyouenoughfortheopportunitythatwasgrantedtomethroughyourRuralResearchCapacityBuildingProgram(RRCBP).IwouldalsoliketoacknowledgeandthankDrEmmaWebsterandDavidSchmidtfromHETIfortheirefforts,theirconstructivefeedbackandtirelesssupport.ThankyoutomyfellowRRCBPcolleaguesespeciallyRachelPitt,ohwhatajourneywehavetaken,thankyousomuchforallyoursupportandforsharingthejourneywithme–Itistimenowtoeatcake.TheManningMentalHealthTeamandManagementofHunterNewEnglandLocalHealthDistrict(HNELHD),Thankyouforallowingmethetimetodothisprojectandforsupportingmewithmymanyhats.MymentorRhondaWilson,foryoursupportandlearningalongtheway.

List of Abbreviations HETI–HealthEducationandTrainingInstituteCAMHS–ChildandAdolescentMentalHealthServicesBOSTES‐TheboardofstudiesteachingandeducationstandardsCIAP‐ClinicalInformationAccessPortalWHO–WorldHealthOrganisationMHFA–MentalHealthFirstAidYMHFA–YouthMentalHealthFirstAidGP–GeneralPractitioner

TableofContents PAGEAbstract 3 ExecutiveSummary 4Introduction 6LiteratureReview 7 Method 13Findings 16Strengths&Limitations 29Discussion 29Conclusion 33 Recommendations 34References 36Appendices 38

U n h e a r d V o i c e s : N o n – s e r v i c e u s i n g m o t h e r s p e r c e p t i o n s o f t h e i r a d o l e s c e n t s ’ s o c i a l a n d e m o t i o n a l w e l l b e i n g .

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AbstractBackgroundOnlyasmallpercentageofyoungpeoplewhoexperiencementalill‐healthwillaccessprofessionalhelpandreceivecare.Youngpeopletendtoturntotheirparentsforsupport,adviceandinformation.Howeverweknowverylittleaboutwhatthissupportlookslikeandhowparentsidentifysocialandemotionalwellbeingintheiradolescentchildren.Thisresearchaimstofindoutwhatparentsobserveandconsiderbeingofimportancerelatingtotheiradolescentchildren’swellbeingandhowtheyrespondtotheirsocialandemotionalneeds.MethodSemistructuredinterviewswereconductedinaninnerregionalareaofAustralia,withninemothersofadolescentchildrenaged12‐17,whoweredeemedoflayknowledge,havingnothadcontactwithChildandAdolescentMentalHealthServices(CAMHS)orseenaprivatepsychiatristorpsychologistfortheirchildren.Thisqualitativestudyusedhermeneuticphenomenologytoguidethematicdescriptionandanalysisofthedata,toexplorethelivedexperienceandidentifykeythemes.ResultsSocialandemotionalwellbeingwasnotsomethingthatparentsdescribedgivingmuchconsciousthoughtto.Theyspokeoffeelingliketheyknewtheirchildrenandbelievedtheywouldbeabletoseechangestoindicateconcerns.Participantsidentifiedtheroleofotherpeople,intheiradolescents’wellbeing.Thiscenteredonthepeopleclosetothemandthepeopletheyfeltknewtheirchildrenwell.Interviewdataindicatedtwooverallthematicareasthatdescribedhownon‐serviceusingparentsperceivedthesocialandemotionalwellbeingoftheiradolescentchildren;‘Mothersperceptionsofknowingtheirchildren’and‘Theinfluenceofothers’.Fivesubthemeswerealsoidentified.‘Thesignificanceoftheparentalrelationship’,‘Thepresenceandabsenceofcontact’,‘Makingconnections’,‘Gainingknowledge’and‘Support’.ConclusionAmotherunderstandingofthesocialandemotionalwellbeingoftheiradolescentchildreniscomplexandconstantlychanging.Thisresearchgivesvoicetothelargegroupofparentswhoarenotcurrentlyaccessingservices,helpingtodevelopasharedunderstandingofwhatworksfortheminpromotingandmonitoringtheirchild’swellbeing.Inherentinthisunderstandingistheperceptionthatmothersknowtheirchildrenandhowtheyareinfluencedbypeopleandexperiences.Byfocusingonthesecorethemes,professionalsmaybebetterplacedtoengageandtargetmentalhealthpromotion,preventionandearlyintervention,topeopleidentifiedbymothersasbeingpartoftheirinformalsupportnetworkaswellastooneofthekeysupportersofadolescentsocialandemotionalwellbeing,mothers.Keywords:Adolescents,mothers,emotionalandsocialwellbeing,mentalhealth.

U n h e a r d V o i c e s : N o n – s e r v i c e u s i n g m o t h e r s p e r c e p t i o n s o f t h e i r a d o l e s c e n t s ’ s o c i a l a n d e m o t i o n a l w e l l b e i n g .

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Executive Summary  ContextAdolescentmentalhealthservicesarebeingdevelopedanddesignedbyhealthprofessionals,basedoninformationfromserviceusingorreferredpopulations.Thecontentofmentalhealthpromotionmaterialsandcampaignsarebasedonstudiesofproblemidentificationofmentalillnessesandhelpseekingpathwaysofthosewhohavealreadyreachedservices.Thevastmajorityofadolescentswithdiagnosablementalhealthdisordersdonotreachspecialistmentalhealthservices.RationaleHealthservicesmaybebetterabletoidentifyfirstepisodesofmentalillhealthinadolescentsbyfocusingmentalhealthpromotion,preventionandearlyinterventioneducationtowardsparentsandcaregivers.Mentalhealthservicesmaybeabletoreducetheimpactofmentalillhealthontheindividualsfunctionalperformance,andtheimpactontheirsocialsystemsincludingtheirfamily,promotepathwaystocare,includinginformalpathwaysandhealthpromotioninitiativesandthereforepotentiallyreducetheneedforspecialistmentalhealthservices.Mentalhealthprofessionalsknowthatearlyinterventionformentalillhealthandhealthpromotion,maypreventamentalillness,mayincreaseresilience,mayidentifymentalillhealthearly,mayreducetheimpactofanillnessandmaysupportrecovery,ifayoungpersonisexperiencingamentalillness(1).

ApproachAqualitativeresearchstudyusinghermeneuticphenomenologytoguidethematicdescriptiveanalysiswasusedbytheresearcher.Theviewsofnineordinaryparents,withlayknowledgeofmentalhealth,theiradolescentchildorchildrenhavingnothadcontactwithCAMHSorseenaprivatepsychologistorpsychiatrist,wereinterviewedusingsemi‐structuredinterviewquestions.Theresearchers’goalwastoexplorelayviewsofsocialandemotionalwellbeinginadolescentsasdescribedbytheirparents.ImplicationsThisresearchhasimplicationsforpolicymakersandadolescentmentalhealthpromotion,preventionandearlyinterventionserviceproviders,duetothelimitedliteratureonnon‐serviceusers’perspectivesofwellbeing.Policymakersandservicesinclude;TheDepartmentofHealth,particularlymentalhealthservicepolicymakerswhoarestrivingtoengageparentsandcarersasintegralstakeholdersinadolescentmentalhealthpromotion,preventionandearlyintervention;TheAustralianInstituteforTeachersandSchoolLeadershipwhoareresponsiblefortheAustralianProfessionalStandardsforTeachers,ensuringstandardsofteachereducationprogramsandTheQualityTeachersCouncilofeachstatewhomonitorcontinuingprofessionaldevelopment;Andadolescentmentalhealthpromotion,preventionandearlyinterventionserviceproviders,responsibleforpopulationhealthinitiative.Thisresearchstudyhasgivenvoicetothepopulationthattheseservicesaimtotarget,asnon‐serviceusingparentsvoiceshaveseldombeenheardandconsideredinserviceandpolicydesign,andimplementation.

U n h e a r d V o i c e s : N o n – s e r v i c e u s i n g m o t h e r s p e r c e p t i o n s o f t h e i r a d o l e s c e n t s ’ s o c i a l a n d e m o t i o n a l w e l l b e i n g .

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FindingsTwomajorthemesandfivesubthemeswereidentifiedtodistinguishhowmothersdescribethesocialandemotionalwellbeingoftheiradolescentchildren.

1. MothersperceptionofknowingtheirchildrenThisthemecapturedtheinherentbeliefthatmothersperceivedthattheyknowtheirchildandcouldidentifytheirsocialandemotionalwellbeingneeds.Mothersknowtheiradolescentchildrenbecauseoftherelationshiptheyhavewiththem,thetimetheyspendwiththemandthroughthepresenceorabsenceofcontacttheirchildrenhavewiththem.Mothersbuiltthisknowledgeandunderstandoftheirchildrenthroughmakingconnectionswiththeirchildren.Variouspersonalconstructsshapedandinfluencedmothers’perceptionsofwellbeingandhowtheyviewedtheiradolescentchildren.

2. TheinfluenceofothersMotherspresenttobethegatekeepersforadolescentsseekinghelpandsupport,playingapivotalroleinsupporting,monitoringandmentoringwellbeing,yettheyalsodescribedtheimportantroleotherpeopleplayedintheiradolescents’socialandemotionalwellbeing.Participantsidentifiedtheimportanceofpeers,community(particularlyschoolteachers,tutorsandcoaches),family(highlightingsiblingsandgrandparents)andfriends,viewingtheseinfluencesattimesasbothpositiveandnegative.Parentsgainedknowledgeandadviceabouttheiradolescents’wellbeingthroughinformalsupports,onlyconsideringseekingformalprofessionaladvicewhentheyhadexhaustedallinformaloptionsorwhentheyfelthelplesstoinfluencetheiradolescentchildren.Recommendations

TheNationalProgramStandardsforTeachersneedstoendorseallteachereducationprogramstoincludeevidencebasedtraininginadolescentmentalhealth.AimingtoincreasethementalhealthliteracyofapopulationidentifiedbymothersasbeinginfluentialonAdolescentsocialandemotionalwellbeing.

Thoseresponsibleforteacher’scontinualprofessionaldevelopment(Theboardofstudiesteachingandeducationstandards(BOSTES)inNSW),needtomakeevidencebasedadolescentmentalhealtheducation(suchasYouthMentalHealthFirstAid)anessentialrequirementundertheteacher’saccreditationpolicy,tosupportcontinuingprofessionaldevelopmentforallteachers.

Makereadilyavailableevidencebasedadolescentmentalhealthtrainingtokeystakeholderswhomothersidentifyassupportingtheiradolescents,suchastutorsandcoaches.

DevelopcollaborativepartnershipsbetweenTheDepartmentofHealthandTheDepartmentofEducation,workingtoincreasethenumberofmentalhealthprofessionalsembeddedinschools.Makingakeypartoftheschoolbasedmentalhealthprofessionals’role,engagementwithparentsandcarersbothformallyandinformally.

Futureresearchneedstovalidateparents’perceptionthattheyknowtheirchildren.Thismaybemeasuredbycomparingadolescentself‐ratingofsocialandemotionalwellbeingwithparentsratingoftheiradolescents’socialandemotionalwellbeing.

Furtherresearchneedstoexploretheimplicationsofadolescentsocialandemotionalwellbeingbeingmeasuredbyparents‘pathic’knowledgeofperceivingthattheyknowtheirchildrenandtheimplicationsthismayhaveonnon‐biologicalparentsorcarersandtheirabilitytoidentifydifficultieswiththeiradolescentswellbeing.

U n h e a r d V o i c e s : N o n – s e r v i c e u s i n g m o t h e r s p e r c e p t i o n s o f t h e i r a d o l e s c e n t s ’ s o c i a l a n d e m o t i o n a l w e l l b e i n g .

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IntroductionTheAustraliangovernmenthasgatheredevidenceofthecostsandbenefitsofearlyinterventionandpreventionactivitiesandhasdevelopedpolicy’sandvariousnationalandstatewidestrategiesthatpromoteYouthMentalHealth(2).Parentsareidentifiedaskeystakeholdersinmonitoringandsupportingsocialandemotionalwellbeingoftheiradolescentchildren,howeverthereislimitedliteratureandguidanceonhowparentsshouldbeengagedinmentalhealthpromotionandearlyinterventionsfortheiradolescents.ResearchcarriedoutbyMissionAustraliaannuallysince2006hasconsistentlyfoundthatyoungpeopleturntotheirfriendsfirstandparentssecondforsupportandadvice(3).Yetthereislimitedresearchintothisareaof‘pre’helpseekingbetweenparentsandtheiradolescents.Anunderstandingofthisinteractionandhowsocialandemotionalwellbeingisviewedbyparents,willinformearlyintervention,promotionandpreventionstrategytargetedatadolescentpopulations.Ratherthanmarginalisenon‐serviceusingorlaypersonsknowledgeasunscientificoruninformed,itmaybeusefultoconsiderthemashavingalternateknowledgetothoseofprofessionals(4).Throughthisprojecttheresearcherquestionswhatmentalhealthliteracyistoparentsofadolescentsbyexploringhowtheyperceiveandthendescribewellbeingfromtheperspectiveoftheexperiencestheyhavewiththeiradolescentchildren.Pastresearchhasfocusedonfindingoutwhyparentsdonotaccessserviceswhentheyneededto,andonwhatinfluencedparentstoaccessservicesfortheirchildren.Thisresearchfocusesonparentswhosechildrenhavenotaccessedservices,somemayhavechildrenwithmentalhealthdifficultiesthathavenotbeenidentified;somemaybemanagingmentalhealthdifficultieswithoutprofessionalsupport.InRogersandPilgrim(1997)(4)researchwithlaypersons,foundtheterm‘mental’followedbytheword‘health’or‘illness’wasregardedinfearfulandnegativetermsandwhenaskedaboutmentalhealththerewasatendencytofocusimmediatelyonmentalillhealthorlearningdifficulties.Inthisresearchstudytheresearcherisusingthetermemotionalandsocialwellbeingtoattempttoaddresssomeofthisstigmaandtoensurebehaviourisnotbeinginappropriatelylabelledassymptomsofanillness.ThesetermsareinlinewiththedescriptionsofmentalhealthoutlinedintheWHOComprehensiveMentalHealthActionPlan2013‐2020.TheActionPlanemphasisesthatinrespecttochildren,developmentalaspects,suchas,havingasenseofidentity,theabilitytomanagethoughtsandemotions,aswellastobuildsocialrelationshipsandtheaptitudetolearnandgainaneducation,enableschildren’sfullactiveparticipationinthecommunity,anddefinestheirmentalhealth.Forthepurposeofthisresearchtheresearcherwillfocusontheagegroup12‐17andwillrefertotheseyoungpeopleasadolescents.

U n h e a r d V o i c e s : N o n – s e r v i c e u s i n g m o t h e r s p e r c e p t i o n s o f t h e i r a d o l e s c e n t s ’ s o c i a l a n d e m o t i o n a l w e l l b e i n g .

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LiteraturereviewBackgroundAClinicalInformationAccessPortal(CIAP)searchidentifiedalargebodyofevidencerelatingtoadolescenthelpseekingandrecognitionofmentalhealthdisorders,therewaslimitedresearchfocusingonparentsperspectivesofhelpseekingandparentsperceptionsofmentalhealthandwellbeing.Furthersearchersmanuallyandvia‘handsearches’ofreferencelistsfromliteratureidentifiedviatheinitialCIAPsearch,revealedthereappearstobeagapintheresearch,withnoqualitativeresearchfoundbytheauthoronparentsperspectivesofAdolescentMentalHealthfromparentswhowerenothelpseekingfortheiradolescentchildren.Theresearcherregularlyscreenedfornewliteratureoverthecourseoftheresearchstudy.Oneinfouryoungpeoplebetweentheagesof16‐24years,willsufferfromacommonmentalillnessinanyoneyear(5).Despitethepotentialimpactofamentalillnessandtheavailabilityofarangeofeffectivetreatments,onlyasmallpercentageofthosewillconsultwithahealthprofessionalabouttheirmentalhealthandevenfewerwillreceivecare(6).Themajorityofmentalillnessgoesuntreated.WithalargestudyintheUnitedStatesreportingthathalfofalllife‐longmentaldisordersstartbytheageof14years(7).Servicesnationallyaretargetingearlyinterventionandpreventionofmentalillhealth,earlyinlife,earlyintheillnessandearlyintheepisodeoftheillness(8).Theprocessforyoungpeopletoaccesshelpforamentalillnessiscomplex.Youngpeopleneedtobeabletoidentifythattheymaybeexperiencingmentalillhealthortheyneedtoexpressorexhibitsignstothosearoundthem,whomareinapositiontoidentifytheseandassistthemtoaccesshelp.Duetotheriskofdevelopingamentalillnessduringadolescenceitisimportantforyoungpeopleandthoseclosetothemtohaveagoodunderstandingofmentalillhealthandtheappropriatestrategiestoaccesshelp(9).Thereislimitedliteratureandguidanceforhealthprofessionalsaroundhowtoengageparentsinmentalhealthpromotionandhowtosupporttheminidentifyingearlysignsofmentalillhealthormentalillness.Theprocessofhelpseekingfromtheperspectiveofparentsseekinghelpfortheirchildrenhasbeenpoorlyexplored(10).Thereislimitedqualitativeresearchonwhatparentsactuallyknowaboutmentalhealthandhowtheymanageandrespondtotheemotionalandsocialwellbeingoftheyoungpeopleintheircare.Wilson,Cruickshank,&Lea,(2012)(11)identifiedaneedforfutureresearchtodeterminetheenablerstofacilitateearlyinterventionamongyoungpeopleandtheirparents,ratherthanthebarriers,toexplorefactorswhichinviteearlyhelpseekingandengagementwithmentalhealthservices.Thereisaneedtogobeyondprofessionalknowledgeandexploreproblemdefinitionfromthosenotseekinghelp,tohelpgainanunderstandingoftheirperspectiveandofwhatinfluencestheirknowledgeandunderstanding(12).Whilemuchresearchhasgoneintothehelpseekingpathwaysandtheperceivedbarrierstomentalhealthcare,mosthavefocusedonthelaterstagesofmentalillnessandaccesstosecondaryhealthservicesorformalservices.Thesestudieshavebeencompletedwithpopulationswhomareseekinghelp,whomhaveaccessedservicesorthroughresponsestovignettesdepictingyoungpeoplewithsymptomsofdiagnosablementalillness(9,13‐16).Researchhastendedtofocusedonreferredpopulations(12‐15)orparentsresponsesto

U n h e a r d V o i c e s : N o n – s e r v i c e u s i n g m o t h e r s p e r c e p t i o n s o f t h e i r a d o l e s c e n t s ’ s o c i a l a n d e m o t i o n a l w e l l b e i n g .

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casestudiesofpersonspresentingwithdiagnosablementalillness(9),ratherthanontheproblemrecognitionandinformalhelpseekingprocesses.Littleisknownaboutthehelpseekingstagesthatparentsgothroughinordertoinitiallyrecognisethatthereisaproblem,makingthedecisiontoseekhelpandthenactuallyseekingoutthatsourceofhelp(12).Studieshavefoundthatfamiliesdevelopskillsinhelpingyoungpeoplewithmentalhealthdifficultiesbeforetheyaccessthemedicallyorientatedprimarycareframeworkthatexistswithinmentalhealthservices(11,17).Thisreviewlooksatliteraturethatexploresadolescentmentalhealthfromtheperspectiveofparentsacrosstheworld.Italsolooksathowpolicy’ssupporttheneedforfurtherresearchinthisarea.TheWorldHealthOrganisation’scomprehensiveMentalHealthActionPlan2013‐2020,aimsforequitythroughuniversalhealthcoverage,takingalife‐courseapproachthatstressestheimportanceofprevention.Recognisingthatanyhealthpoliciesandprogrammesneedtofocusnotonlyontheneedsofpeoplewithdefinedmentaldisorders,butalsotoprotectandpromotethementalwell‐beingofallpeople,recognisingthereisanimportantroleinlookingatprotectivefactorsparticularlyforchildrenandadolescentsandtheimportanceofpromotingmentalhealthandpreventingmentaldisorder.PrioritiesforpromotingyouthmentalhealthinAustraliahighlighttheneedforactionandadvocacythatacknowledgestheneedsofparentsandfamiliescaringforadolescents(18).Thereview,usingthefiveplatformsoftheOttawaCharter;publicpolicy,supportiveenvironments,communityaction,personalskillsandreorientationofhealthservices,highlightedtheneedforinvestmentinresourcesforparentsandfamilies(18).Rickwood(2011)(18)statedthatthisgrouphavedistinctneeds,andthatactionandadvocacywereneededtoacknowledgeandaddresstheneedsofparentsandfamilies,toknowhowtobettersupportthementalhealthofthosetheycaredfor.TheWorldHealthOrganisation(19)statesthatoneofthemaincharacteristicsofmentalhealthpromotionalstrategiesismakingacommitmenttoexploreandvaluelayunderstandingsofmentalhealthandtodevelopappropriatestrategiesandprogrammesitiscrucialtoidentifytheneedsinapopulation.HelpSeeking.Whyfocusonparents

Therearemanyformalandinformalsourcesofhelpthatareaccessedbeforethedecisionorthepathwayleadstomentalhealthservices.Fewstudieshavefocusedontheinitialstagesofhelpseeking,identifyingtheneedforhelp,whichmaybeimportantforunderstandingwhoinitiatesthehelpseekingprocess(20).ResearchundertakeninruralCanadafoundthatyouthsuseofinformalhelperswasdependentonageandtowhatdegreetheydefinedthemselvesashaving‘problems’(20).ArecentAustralianstudytargeted15‐19yearoldsacrossAustralia,foundwhenchoosingfromalistofidentifiedsourcesofhelpthatyoungpeoplerankedfriendsfirst,followedcloselybyparentsforwhotheyturntowhenlookingforadviceandsupportandratedparentssecondtotheinternetwhenlookingforinformation(21).AnationalAustraliantelephonesurveyin2006,foundwhenaskedwhotheywouldturntoforhelpiftheyoraclosefriendpresentedwithsymptomsoutlinedinanumberofmentalillnessvignette,thatfortheadolescentgroupsurveyed,familywerebyfarthemostcommonlymentionedsourceofhelp(9).Coresidentparentsofthosesurveyedwerealsoaskedquestionspertainingtovignettesofyoungpeopletheirchild’sage,portrayingeither

U n h e a r d V o i c e s : N o n – s e r v i c e u s i n g m o t h e r s p e r c e p t i o n s o f t h e i r a d o l e s c e n t s ’ s o c i a l a n d e m o t i o n a l w e l l b e i n g .

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depression,depressionwithalcoholmisuse,socialphobiaorpsychosis(9).Ofthechoicesofhelpgiven,usingaclosed‐answerformat,GeneralPractitioners(G.P’s)werethemostfavouredsourceofintendedhelpbyparents,howeveritisunclearhowcloselythereportedresponsestovignettestranslatesintoactualparentingbehaviourwithparentsownchildren.Broadhurst,2003(12)inherreviewoftheresearchonhelpseekingandhowitmayinformtheengagementofparentsandcarerswithfamilysupportservices,foundthattheprocessusedbymotherstodefineaprobleminrelationtotheirchildaroseoutofinteractionsbetweenthemothers’ownknowledge,culturallyavailableunderstandingsandtheirprofessionalknowledge.Motherswerereferredtoas‘thegatekeeper’toservices(12).Suggestingthatitishowmothersdefineproblemswhichdetermineshow,whenandwhytheywillaskforhelp,withmothersbeingfoundtoapproachprofessionalserviceswhentheyarrivedatanunderstandingthattheychildren’sbehaviourwasoutside‘thenormalrange’(12).Fuller,Edwards,Procter&Moss(2000)(22),underpinnedtheirresearchwiththebeliefthatthefirststepinthepathwaytoseekinghelpwastherecognitionofsymptomsofdistressinoneselforinothers.Theirresearchexploredhowpeoplesdefinitionsofmentalhealthproblemscaninfluencehelpseekinginruralandremotecommunitiesandstudyparticipantswere22‘keyinformants’whoweredescribedasbeingknowledgeableaboutmentalhealthproblemsintheircommunities,theyrangedfromateacherandmentalhealthprofessionalstomentalhealthserviceconsumers(22).Theresearchersfoundthreemajorthemesemergedfromtheirdataregardingdefinitionofmentalhealthproblems;1)Reluctancetoacknowledgementalhealthproblemsandavoidanceofappropriatehelp,2)Stigmaandtheavoidanceofmentalhealthservices,3)Ruralandremotecircumstances(22).Thesefindingsraisedfurtherquestionsaboutthedeliveryofmentalhealthservicesinruralareasandhowtoincludementalhealthpromotionaspartofservicesdeliveryandraisedquestionsaroundthebestpeopleplacedtoprovidecareinthesepotentiallyisolatedcommunities(22).Helpseekingmodelswouldsuggestthatthedecisionforanadolescenttoseekhelpstartswiththeirdevelopmentofanawarenessoftheproblem,thentheirexpressionoftheproblemandneedforhelptoothers,identifyingappropriatehelptoaccessandtheirwillingnesstoengagewiththesourceofhelp(23).Littleisknownifthissamemodelappliestoparents,norabouttheresponsesparentshavetoadolescents’awarenessorunawarenessofproblemstheypresentwith,howparentsidentifysupportsordirecttheiradolescentchildrentoresourcesorhowtheyfindoutabouttheseresources?Whatpromptsparentstothinktheiradolescentneedsmoresupportwithanissuethantheycangivethem?Whatguidestheirdecisionmakingwhenitcomestomanagingdifficultiestheiradolescentpresenttothem?

ProblemRecognition

Researchexploringparentalrecognitionofmentalhealthproblemshasbeencompletedfromtheperspectiveofwhatparentsidentifyassignsofmentalillhealth,withresearcherspreferringtousestandardisedscalesandmeasures(24).Vignettesdepictingpeoplewithmentalillnesseshavealsobeenusedtoresearchparentsproblemrecognitionofmentalillnessandtheirproposedpathwaytosupports(16).Lessstillhasbeenfoundontheparents

U n h e a r d V o i c e s : N o n – s e r v i c e u s i n g m o t h e r s p e r c e p t i o n s o f t h e i r a d o l e s c e n t s ’ s o c i a l a n d e m o t i o n a l w e l l b e i n g .

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perspectiveofearlysignsofmentalillhealthwhentheysupportyoungpeoplewhomhavenotbeenidentifiedasneedingprofessionalsupport(9,25).Inmoststudiesprofessionalshavedefinedtheproblemstypicallyusingquantitativeapproachesandaskedparticipants‘whatif’questionstoexploreproposedpathwaystocare(16).Limitedresearchexistsexploringwhatsymptomsorbehaviourparentsrecogniseasbeingproblematicintheiradolescentchildren.AlongitudinalstudyintheUnitedStatesofAmerica,onmentalhealthproblemrecognitionfoundoverhalfofparentsofchildrenassessedtohaveamentalhealthdiagnosisdidnotperceiveproblems(26).Thisstudyusedstandardisedassessment,oneofwhichwasinterviewbased,howeverusedstructuredquestionslookingforsymptomsasoutlinedbyanextensiveglossary,potentiallymissingthelaypeoplesdescriptionsofproblemperceptionormentalillhealth(26).Howanadolescentandtheirparentorcarerdefineandjudgetheproblemsthattheyface,influenceshelpseeking(26,27).Teagle(2002)(26)suggestedthatparentsandcaregiversneedtobeeducatedtohelpthemidentifyseriousmentalhealthproblems,howeverdidnotexplorehowtoengageparentsnorifthisshouldbetargetedoruniversalpopulationpromotion.Otherresearchhasfoundthatoftentheoutcomeofwhetherayoungpersondevelopedamentaldisorderwasdependentontheirparentsresponsetotheirbehaviour(9).Whenpresentedwithvignettesthatresearchersbelievedportrayedyoungpeoplewithdisordersthatclearlywarrantedprofessionalhelp,researchersfoundyoungpeopleweremoreunlikelythanadultstoseetheneedforprofessionalhelp(9).Researchintoadolescentsresponsestoaseriesofstandardisedquestionnaires,exploringlevelofperceivedproblemsandadolescenthelpseeking,foundthatfurtherresearchneededtobecarriedoutto“examinehowyouthsperceivesymptomsandwhethertheydistinguishbetweensymptomsthatarepartoftheproblemitself(egdepression,substanceabuse)andsymptomsthatarearesponsetoaproblem(eg.Familyproblemoracademicproblem).”(Sears,2004:403)(20).Fuller,Edwards,Procter&Moss(2000)(22),foundthatpeopletalkedaboutmentalhealthproblems,notasdiseaseorillnessstates,butasproblemsineverydayliving.AUnitedKingdombasedstudyusedacombinationofinterviewsandfocusgroupsaswellasastandardisedscale,withparentsofchildrenandadolescentswhowereconcernedabouttheirchild’semotionalhealthorbehaviour(13).Theresearcherswishedtoexploretheinfluencesonparentalhelpseekingofapopulationthathadnotyetaccessedchildandadolescentmentalhealthservicesyetwereaccessingprimaryhealthcareservicesforsupport(13).Ofinterestintheirfindingswasthethemeof‘parentalperceptionandknowledge’whichoutlinedthedifferentviewsbetweenparticipantsoftheroleoftheGPinhelpseekingforbehaviouralandemotionalproblems,withsomenotingtheseproblemsasnotbeingduetohealthconditionssotheydidnotseeitasnecessarytodiscusstheseconcernswiththeirGP(13).Thisraisedquestionsaboutmentalhealthliteracyandparentsperceptionsofemotionalandbehaviouralproblems,andmustbeexploredfurtherifwearetomakeadifferenceinmentalhealthpromotionandtheearlyidentificationandtreatmentofmentalillnessinyoungpeople.SimilarlyarecentqualitativestudyinAustralianwithparentswhomhadsorthelpfortheirchild’smentalhealthproblems,wereinterviewedtoelicittheirexperiencesofhowtheyperceivedtheirchild’sproblems,howtheparentcoped,andtheinfluencesonhelpseeking

U n h e a r d V o i c e s : N o n – s e r v i c e u s i n g m o t h e r s p e r c e p t i o n s o f t h e i r a d o l e s c e n t s ’ s o c i a l a n d e m o t i o n a l w e l l b e i n g .

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(10).Throughthethematicanalysisofinterviewstheresearchersfoundthathelpseekingpathwayswereinfluencedbythetypeofproblemexperiencedbytheyoungpeople,thosewithprimarilybehaviouralproblems(usuallyyoungerchildren)werereferredtoservicesbyparentsandthosewithemotionalproblemsenteredintohelpseekingviabothteacherandparentinitiatedpathways(10).Mostoftheparentsnotedthattheyhadbeenpromptedtoseekhelpduetonotbeingabletomanagetheirchild’sproblemthemselves(10).DifferingfromUKbasedresearch(13),theAustralianbasedstudybyBoulter&Rickwood(2013)(10)foundthatparticipantshadincommonthattheyhadallaccessedaGPintheirhelpseekingpathway,inlinewiththeAustralianHealthcaresystem,asanecessitytoaccesspsychologicalservices,howeverthiswasastudyofparentsreceivingservicesfrommentalhealthprofessionals.Stigmaandshameexistsaroundthetermmentalillnessormentalillhealth,andthisimpactsnotonlyonhelpseekingbutalsoontheidentificationofillnessinthoseincloserelationships(9).Althougharelativelyoldstudy,Rogers&Pilgrim(1997)(4)studyofexplorationintotheprocessofunderstandinghowindividualsarriveatandappraiseproblemrecognition,continuestobesightedintheliteraturetoday,asitisoneofthefewqualitativestudiesthatfocusedonlayconstructsofmentalhealthproblems.InthisUKbasedstudytheresearchersexploredtheviewsof‘ordinary’,‘non‐clinical’peopleinavarietyoffamilytypeswithteenagersandchildren(4).Respondentsconsistentlyprovidedelaboratedescriptionsofphysicalhealthinessandmentalillness,butgave‘poor’accountsofmentalhealthiness(4).TheresearchfoundthatGPswerenotviewedastheprimarysourceofemotionalsupport,withprofessionalhelpbeingviewedasalastresortwhenlaynetworksandself‐reliancehadbeentried(4).RogersandPilgrimin1997,highlightedthattheirfindingsindicatedaneedtoexpandandbeinnovativewithprimarycareservices,extendingorre‐orientatingtheroleofprimarycareprofessionalsandrespondingtothenon‐helpseekersagendainrelationtopsychologicalwellbeing(4).MentalHealthPromotion,PreventionandEducationstrategies

Thereisoverwhelmingevidencethatthefoundationsforlifelongmentalhealthbeginsinchildhood,particularlyinadolescence,atimewhenmentalillhealthispoorlyidentifiedandundertreated(1,28).Thereisgrowingmomentumamongstpolicymakersandservicedeveloperstoaddressthementalhealthneedsofyoungpeopleandtheirfamilies(26).Theneedforpeopletohaveabetterunderstandingandrecognitionofmentalhealthproblemsandmentalillnessisindicated,withchangebeingmonitoredbylookingattheratesofunderstandingofmentalhealthproblemsandmentalillnessinthecommunity,howeverlittleisstatedabouthowmentalhealthliteracywillbeimprovedandhowincreasesinunderstandingandrecognitionwillbemeasurement(8).Traditionalclinicaldrivenapproachestomentalhealtharebeingchallengedtotransformationalchangetoensuretheyaremoreinclusiveandempoweringofyoungpeopleandtheirfamilies(29).Stakeholdersinmentalhealthservicedevelopmentarebeingchallengedtolistentotheexpertiseofyoungpeopleandtheirfamiliesinordertoachieveprogressiveservicedevelopmentandsystemicchange,andreflectsaminimumstandardthatyoungpeopleandtheirfamiliesshouldexpectfrommentalhealthservices(29).Licence(2004)(1)inherliteraturereviewofhealthpromotioninchildhood,boundthepromotionofpositivementalhealthinchildhoodwithpositiveparenting.Othershave

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proposedthatparentsandcarersareinaninfluentialpositiontopromotementalhealthinthoseintheircareandthatbyraisingawarenessofthepositivecontributionparentscanmaketheycanpositivelyinfluencecausalpathwaysbyenhancingprotectivefactorsformentalwellbeingforthoseintheircare(30).Howeverifwecannotengageparentstoattendawarenessraisingcampaigns,orifwecanbychanceengagethem,weneedtomakesurewearedoingsoattheirlevelofinterest,usinglaypersonslanguageandaddressingtheirprioritiesforyouthmentalhealth.Learningmoreabouthowparentsidentifyandcopewiththeiryoungperson’ssocialandemotionalwellbeing,willhelpbetterinformprofessionalsincludingpolicymakerstounderstandinformalhelpersandassistprofessionalstoworkwithparentsaroundmanagingtheiryoungperson’swellbeing.Thiswillensureappropriatesupportsandhelpareaccessedwhentheyareneededtosupportearlyinterventionwithmentalillhealth.Theliteraturereviewhashighlightedtheneedforfurtherresearchthatsupportsustounderstandhowparentsviewsocialandemotionalwellbeing,whyandhowindividualsmakedecisionstoseeksupportandinformationonavoluntarybasis.Thiswillhelpformnewapproachestoservicedeliverythatlooktoincreaseearlyinterventionrates,targetingoneofthemostinfluentialsupportersofadolescenthelpseeking,parents.

ResearchQuestion

Goal:Toexplorethelayviewsofsocialandemotionalwellbeinginadolescentsasdescribedbytheirparents.

PrimaryObjective:Totalktoparentsandgainafirstperson,in‐depthunderstandingofwhattheyperceivetobecharacteristicsofemotionalandsocialwellbeingintheiradolescents.

SecondaryObjectives:

Togainanunderstandingofthelanguageparentsusetoidentifyemotionalandsocialwellbeing.

Forhealthprofessionalstogainanunderstandingofhowadolescentmentalhealthneedsemergeandareidentifiedandexpressedbyparents.

Togainanunderstandingofhowparentsrespondtoemotionalandsocialwellbeingconcernstheyortheiradolescent(s)identify.

Tounderstandwhatinfluencesparentsdecisionmakingwhenmanagingemotionalandsocialwellbeingissuesraisedbytheiradolescent(s).

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Method  

Methodology

Thisqualitativestudywasguidedbyhermeneuticphenomenology.Theinterviewerengagedparticipantsinanexplorationofhowtheyviewedsocialandemotionalwellbeing,givingthemthespaceandopportunitytoreflectonthelivedexperienceoflifewiththeiradolescent.UsingHeidegger’shermeneuticphenomenologytheresearchersoughttogainanunderstandingofthephenomenonofinterestatapointinhistoricaltime,thephenomenonbeingwhatparentsperceivedtobesocialandemotionalwellbeingandtimebeingthispointintheirchild’sadolescence.Heideggerviewedpeopleasbeingconstructedbytheworld,whileatthesametimepeopleareconstructingthisworldfromtheirownexperiencesandbackground,fromoneshistoricality(31).

Participants&Recruitment

Semi‐ruralresidenceonthemidnorthcoastofNSW,Australia,wereinvitedtoparticipateintheresearchproject.Participantswererecruitedthroughvariousmeans.Amediareleasetolocalradioandnewspapers(AppendixOne)initiatedradio,newspaperandtelevisioninterviewswiththeresearcher.Acopyofthemediareleasewasalsoplacedinlocalinformalandsocialsettings,suchaspublicnoticeboards.Theresearcheralsospokeabouttheresearchtoherpersonalandprofessionalnetworkstoinformpeopleoftheprojectandtherecruitmentprocess.Participantswereselectedbasedonthebelowcriteriaandtheirwillingnesstotalkabouttheirexperiences.

Inclusioncriteria; Parentofanadolescent(aged12‐17). Aresidentofthesetgeographicalareaonthemidnorthcoast,definedbythe

AccessibilityRemotenessIndexAustraliaasinnerregional.Exclusioncriteria;

Parenttooneormorechildrenovertheageof18years(eveniftheyalsohadadolescentsbelowthisage).

HavingachildwhomiscurrentlyorhaspreviouslybeenunderthecareofCAMHSoraprivatepsychologistorpsychiatrist.

Parentsofadolescentaged18yearsoroverwereexcludedduetoresearchfindingsthatparentandadolescentrelationships,includingsupportnetworksandboundaries,changearoundthisage(9,32).ParentsofadolescentswhomhadbeenreferredandorseenbyCAMHSorprivatepsychologistorpsychiatristswereexcludedfromthestudy.Exclusionsoftheseparentswasfeltnecessaryasthecontactwithmentalhealthprofessionalssuggeststheparentsoftheadolescenthavealreadybecomeawareofamentalhealthconcernthathasleadtheadolescenttoaccesssupportfromspecialistmentalhealthservices.Itwouldalsosuggesttheymayhavespokentoamentalhealthprofessionalabouttheiradolescent,influencingthereknowledgeandexperienceofmentalillhealth(4).Itisbelievedtheseconversations

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orinteractionswouldinfluencetheparents’perspectiveofwhatconstitutesan‘important’issue,influencingemotionalandsocialwellbeing.Theresearcherwishestoexplore‘pre’helpseeking,theearlieststagesofhelpseekingandhaveparentsidentifywhattheyseeasimportantissuesfortheemotionalandsocialwellbeingoftheiradolescents.

Twentyfourpotentialparticipantsvolunteeredtojointhestudybyphoningtheresearcherfromcontactdetailsprovidedonthemediarelease(Appendixone).Ofthese,ninewereeligibleandreceivedverbalinformationaboutthestudy,withfurtherinformationmailedoremailedtothevolunteers(AppendixTwo&AppendixThree).Allnineparentswhometcriteriaparticipatedintheresearchstudy.Interviewswereundertakeninavarietyoflocationsincludingparticipants’placeofwork,thelocalcommunityhealthcentre,alocalparkandtheparticipants’homes.Interviewsrangedfrom40minuteto75minutesinlength.InterviewswerecarriedoutoverasevenmonthperiodfromSeptember2013toApril2014.

Theresearcheralsousedsnowballingtorecruitparticipants.Oncompletionoftheirinterviewwiththeresearcherparentsweregivencopiesofthemediareleaseandencouragetopassthisinformationontoothersinthecommunity,howevernoparticipantreportedbeingrecruitedinthismanner(33).

DataCollection

Oneononeinterviewswithparticipantswerecarriedoutbytheresearcher.Asemistructuredinterviewwasusedwithpredeterminedopenquestionsandprompts(AppendixFour),withfollowupdiscussion,ledmostlybytheparticipants,attemptingtostayasclosetothelivedexperienceaspossible(31).Throughthisinterviewtechniqueparticipantsweregiventheopportunitytotelltheirstories,tospeakfreelyandreflectively,andtodeveloptheirideasandexpressandexplorewiththeresearchertheirperceptionsatsomelength(33,34).Theresearcherencouragedparticipantstointerprettheirownresponsesthroughexploratoryquestionssuchas“whatdoyouthinkinfluencedyoutothinkorrespondlikethat?”.Interviewsweredigitallyrecordedusingtwodifferentrecordingdevicesandallinterviewswereincludedintheanalysis.

Interviewsrecordingsweretranscribedverbatim,bytheinterviewerandthematicallyanalysed(35).Allparticipantswereofferedacopyoftheirtranscription,threeparticipantsrequestedcopies,ofthesenonemadeadditionalcomments.Theresearcherkeptareflectivediaryofeachinterview,notingtheenvironmentoftheinterviews,non‐verbalcommunication,theinterviewers’internaldialogueandexternalinfluencesandcapturingthoughtsandfeelingsoftheresearcherpostinterview,tosupportself‐reflexivityandtoassistininterpretingtheexperiencesoftheparticipants(31).Notesweretakenbytheresearcherduringtheinterview.

Inkeepingwithqualitativeresearch,interviewingceasedwhenanalysesoftheinformationcollectedbyparticipantsreachesapointofsaturation,inwhichcasetheobjectiveoftheresearchquestionwasattainedandwouldnothavebeenmadeanycleareriftheresearchercontinuestodofurtherinterviews(35).Thesamplesizeofnine,wasbelievedtohavebeenlargeenoughtocapturearangeofparentsinterpretationsofadolescentwellbeing,thiswasfoundintherepetitionofthemesthatemergedthroughtheprocessofdataanalysis(36).

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DataAnalysis

Theresearcherwishedtoformapartnershipwiththosebeingresearchedtohavethemresearch‘with’them.Participantswereencouragedtoreflectwiththeresearcheronhowtheyperceivethewellbeingoftheiradolescentchildrenandtoreframethephenomena.Interviewsandanalysisoccurredsimultaneously.Usingthematicdescription,subjectiveanalysesofthetranscriptsoccurredtoexploretheparentslivedexperienceandthemeaningwhichtheymadeoftheirexperienceofadolescentsocialandemotionalwellbeing(33,34).In‐depthanalysisidentifiedmanycodes,withtheresearcheremphasizingbothconvergenceanddivergence,commonalityandnuancesacrossallparentsinterviewed(33).Transcriptswerereadandre‐readtochecktheresearcher’ssubjectivityininterpretationofcodes,withcodesandthemescriticallydiscussedwiththeresearchersmentorandsupervisors.

Theresearcherimmersedherselfintheactofreadingliterature,reflecting,readingherreflectivejournal,re‐readingparticipants’transcriptsandengagingincriticaldiscussionswithhermentorandresearchsupervisors,allexperiencedresearchers.MicrosoftOneNotewasusedtomanuallycutandpastetranscriptsintoseparatepages/notestoidentifycodesastheywereidentifiedfromthedata,thisbeinglabelledasthefirstlevelofanalysis,exploringwhattheparticipantssaidintheinterviews.Thesecondlevelofanalysisinvolvedlookingatwhatthey,thecodesactuallymeant,todeterminethethemesofthedata.Thiswasachievedthroughcriticaldiscussion,firstlevelcodesweresiftedandsortedintopotentialmainthemes(secondlevelthemes)thatevokedadeeperunderstandingofthephenomenabeingstudiedandbestansweredtheoriginalresearchquestion.Theresultsarediscussedin‘Findings’.Significantquotesfromparticipantswereidentifiedandattachedtothemestogivethereaderanappreciationoftheirimportance.Allnameshavebeenchanged.

ReflexivityTheresearcherisanexperiencedmentalhealthOccupationalTherapistwithaMastersinAdolescentMentalHealth.Sheisanoviceresearcherwithsomepreviousexperiencecollectingdataforalargequantitativestudy.Theresearchergaveconsiderablethoughttoherownexperienceasaparentwhencollectingdataandwasconsciousoftheseviewsnotbeingreflectedduringtheinterviewprocess.Thereflectivejournalwasusedtocapturethesethoughtsandtoassistwithself‐reflectionandthematicanalysis,supportingthehermeneuticapproach(31).Theresearcherhaddevelopedthisprojectwiththeassumptionthatparentscaredaboutthesocialandemotionalwellbeingoftheirchildren.Theresearchers’personalexperienceasacliniciancurrentlyworkinginadolescentmentalhealthpromotion,trying,unsuccessfully,toengageparentsofadolescentsinthepromotionofmentalhealthandearlywarningsignsofmentalillhealth,promptedthisexplorationofhowparentsperceivethesocialandemotionalwellbeingoftheiradolescentchildren.EthicsEthicswasobtainedon27/06/13withsitespecificassessmentapprovalbeinggrantedon06/8/13bytheHunterNewEnglandResearchEthics&GovernanceUnit,NewLambton,NSW,Australia.

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FindingsThenineparticipantsinterviewedforthisstudywereallmothers.Allweremarriedorinadefactorelationship.Alllivedwiththeiradolescentchildren.Twowerenotlivingwiththefatheroftheadolescentsfocusedonininterview.Allwereemployedfullorparttime.Sevenhadmorethanonechild,howeveronlytwohadmorethanoneadolescentchild.Themeanageofthe11adolescentstheinterviewsfocusedonwas14.2yearsand80%weremales.Twomainthematicareasthatcapturedthephenomenaweregeneratedfromanalysisofthedata,withfivesubthemesfoundwithinthesetwomainthemes.

1. Mothersperceptionofknowingtheirchildren1.1 Thesignificanceoftheparentalrelationship1.2 Thepresenceorabsenceofcontact1.3 Makingconnections

2. Theinfluenceofothers

2.1 Gainingknowledge2.2 Support

Participantsbuildtheperceptionsofsocialandemotionalwellbeingthattheyhavefortheiradolescentchildrenaroundtheirpersonalexperienceswhichareshapedandinfluencedbytheirculturalandsocialpractice.

1. Mothersperceptionsofknowingtheirchildren.

Allmothersdescribedknowingtheirchildren.Knowingwasviewedbyparticipantsasaninherentunderstandingofwhotheirchildrenare,theirpersonality,howtheymanageandrespondtolifeanditschallenges.Themothersdescribedunderstandingtheiradolescents’wellbeingasbeingwhattheynoticeandsurmisethroughspendingtimewiththem,watchingthemgrow,develop,transitionandexperiencetheworld.Mothersunderstoodthistobetheirrole,toknowtheirchild.

“Ifeelthatyouknow,youcertainlyknowyourownchildren,surelybythetimetheygettoteenagers….youjusthavethatinnergutfeelingthatthereissomethingwrongwithyourchild,likeyouknow,ithasn’tbeenagoodweek,or,that’showIlookatit”Debbie

“Idon’tknow,justknowinghim,Ithink,justbeingwithhimsomuch.Ijustknowhim”Alice

Theparticipantswereabletoidentifyeachchild(forthosethathadmorethanonechild)ashavingtheirownwayofexpressingthemselves,bethatinternalisingorexternalisingtheirfeelings.Mostdidnotspecificallyrelatethistotheirgender,butrathertowhomtheywere,theirpersonalityandtheirgeneticmakeup.

“Wearegoingtohavetohandlehim[middlechild]verydifferently,…Icanalreadyseehe

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wouldbetheonethatwewouldneedtowatch,becauseheisalotmoreemotional.Iwouldbemoreconcernedabouthim,slippingdownthatslipperyslopetodepressionaloteasierthanwhat[eldestchild]would.Ithink[middlechild]readsintothingsalotmorewhere[eldestchild]justsortofskimsalong.SoIthinkthemoreyoustarttoreadintothings,thenyoucankindofgetyourselfabitunstuck”Fiona

Ofimportancewastheideathatmothersknewtheirchildrenthroughintuitiverecognitionandthroughknowinghowtheirchildrenexpresseddifficulties,verballyandnon‐verbally.Knowingenabledthemtoidentifychangesintheirchildren’sbehaviour,whenandiftheyexperienceddifficultieswiththeirsocialandoremotionalwellbeing.

“Youcantellstraightawaywhatkindofmoodheisinjustfromthelookonhisfacereallyandthetoneofhisvoiceandyehandthetime,andthetimehespendsaroundyouaswell”Beth

“Heisanopenbookhecan,Idon’tknowhowtoexplainit.Heisveryanimated,veryyoucanreadhiscuesandhisfacialexpression”.Cara

Whenmothersdescribedthingsasgoingwell,familiesinteractionsappeartooccurspontaneouslyandinatransparentfashion.Mothersthatidentifiedperiodswhentheirchilddidsomethingunexpectedoroutofcharacterreflectedthattheycouldnotaccuratelyjudgetheirchildren’sbehaviour,andspokeofguiltandembarrassment,orsawthisasalearningexperienceandpartoftheirchildgrowingupandgettingtoknowtheirchild.Onemotherdescribeslearningabouttheinherentnatureofhersons’developmentaldisabilityashedevelopedintoanadolescent.Shespokeofherneedtoadaptcommunicationtomeethisneeds,constantlytryingtolearnfromhersontohelpunderstandhimbetterandtobeabletosupporthiswellbeing.

“Iknewthere[were]allthesefrustrationsandangersandstuffinthere,andum,andheisprobablynotgoingtovolunteerit.SoIsortofgottohandleitinawaywhereImightbeabletowork[it]out…yougottosortofhavetheconversations”Ingrid

Whilemothersrecalledtheimportancethatknowingtheiradolescentchildhadontheirinterpretationoftheirchildren’s’socialandemotionalwellbeing,theyalsoidentifiedthatknowingtheirchildrenwasnotalinearprocess.Oneparticipanthighlightingthatparentscanreallyonlysurmisetheiradolescents’wellbeingandalthoughparentsmayfeeltheyknowtheirchildrenitisreallytheirperceptionofknowingtheirchildren.

“EvenifyouaretheparentofyourownchildIcan’tseethatasecondpersoncoulddescribehowsomebodyelseisthinking…Wellit’sonlywhatyouperceivethattheyarethinkingandfeeling,isn'tit?”Ingrid

Theresearcherfoundverylittleliteratureavailableexploringhowmothersperceivedtoknowtheirchildren.Yetthisseemstobeinherentintheparticipant’sresponseswhendescribingthephenomenaoftheirchildren’swellbeing,thattheymeasurewellbeingandidentifyproblemsthoughknowingtheirchild.Usingaphenomenologicalpointofreferencethisknowing,maybeviewedaspathicknowledge,understandingthatitisfelt,ratherthanthought,andseeminglysoinherentthatitisinvisible(34).Therewasvariousexperiences

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thatinfluencedthispathicknowledgewhicharedescribedasthesubthemesunderthismajortheme.

1.1 Thesignificanceoftheparentalrelationship

Therelationshipthatmotherstalkedabouthavingwiththeiradolescentchildren,wasofsignificantimportancetoknowingtheirchildren.Thisincludedtherelationshiptheyperceivedtheirchildrenhadwiththeirfatherorstepfather.Mothersdescribedknowingtheirchildasbeingtheirresponsibilityortheirroleasaparent.Participantstalkedabouttheirobligationsandthatoftheirpartners,asbeingtogivetheirchildrengoodvaluesandsupport,backingthemupwhennecessaryandestablishinggoodboundaries.Thesefoundations,whicharebuiltfromtheparentalrelationship,createdgoodsocialandemotionalwellbeingfortheiradolescentsandsupportthedevelopmentofresilience.

“It’snotnecessarilygoingthroughthehardthingthatisgoingtocause[him]aproblemit’showwehandlethehardthingsthatcancauseaproblemornot”Elizabeth

Beingagoodrolemodelwasofsignificancetomothersastheyidentifiedtheirchildrenmirrortheirbehaviourandmoods.

“Hewouldjustescalate,andIwouldescalateandyouknowIwouldbeyellinghewouldbeyelling.Hewouldfeelcrapabouthimself,Iwouldfeelcrapaboutmyselfandthethingthatworriedmeaboutthatwasthat,hewaslearning,hewouldlearnthatIcouldn’thelphimorsoothhimorcomforthimandIwaslearningthattoo.IwasthinkingIcan’tcomfortmychildorhelpthemifsomethingiswrong.SoIkindofworkedoutthatwasn’tgoodforeitherofus”Elizabeth

Eachparent,includingstepparents,playeddifferentrolesinsupportingtheiradolescentandchildrensourcedthesupporttheyneededfromwhowasgoingtobestprovideit.

“Isaidto[son]‘doyoureallythinkMumscanfixeverything?’‘Nahnotreally,butyouknow,IjustknewyouwerestrongerthanDad’.Youknow!Soheseesthatasinusasparents,thatDadistheweakerlink.Youknow!Mumsjustgo.Mumsanorganiser.Youknow!Dad,Dadsjust,Dadsourconfidant.Mumsanorganiser.AndIthink,theyknowthat…Theywillgoto[Dad]forcertainthingsbuttheywillcertainlycometome,youknow!Whenthingsarelooking,youknow!Rough”Debbie

Participantstalkedabouttheexpectationstheyperceivedthatothersputontheirparentalrelationship,forexamplesschoolstaffexpectingparentstomanageasuspendedchildathomewithnoguidanceorsupportfromtheschool,andotherparents,includingfathersandstepfathersperceivedexpectationsofmothers.Mothersfeltliketheyhadfailedasaparentorlettheirchildrendown,becausetheydidnotknowhowtodealwiththeirchild’sbehaviourwhensomethingwentwrongfortheirchild,liketheygotintroubleordidsomethingunexpected.Thiswaswhensometalkedaboutnotreallyknowingtheirchildandasenseofguiltathavingletthemdownorhavingfailedintheirparentalrelationshipwiththeirchild.

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“Whenshewasintroubleatschool,likewhenshewassuspendedlastyear.Iactuallyhadnoidea,untillike,untillaterIkindofwent,Ohhhhyouknowlike,youknow,…Ijustdidn’trealise…IwasshatteredbecauseIhadnoidea,thatitwasthatbad.AndIthinkIfeltbadbecausethatwas,Iwasjustguttedreally”Heidi

Parentalrelationshipsweredescribedorsurmisedtostarttochangeinlateadolescence.Mothersspokeaboutthegrowinginfluenceofothersandhowtheirsignificanceortheirinfluenceontheiradolescentchildren’swellbeingchangedastheydevelopedmoreindependencefromtheirparents.

Parentshaveformanyyearsbeenidentifiedasbeingoneofthemostcommonsourcesofsupport,adviceandinformation(3,26).Thesefindingshaveexploredtheparentsperspectiveofthisinteractionandsuggestthatadolescentschoicesforhelpseekinggobeyondthesimpledefinitionofparents.Theparentalrelationshipplaysasignificantroleinhowandwhoprovidessupportandadvice,withmotherssuggestingthisrelationshipcaninfluencestheiradolescent’ssocialandemotionalwellbeing.Literaturesupportsthisideawithasignificantpositiveassociationbetweenparentalmentalhealthandthementalhealthandhappinessoftheirchildren(1).

Thesignificanceoftheparentalrelationship,issupportedintheliteraturewithothersfindinggoodevidencetosupporttheneedforatleastonegoodparent‐childrelationshipbeingassociatedwithgreateremotionalresilienceandpositiveself‐esteeminchildren,bothprotectivefactorsforgoodmentalhealth(1).

1.2 Thepresenceorabsenceofcontact

Mothersmeasuredsocialandemotionalwellbeingthroughthepresenceorabsenceofcontactwiththeiradolescent.Participantsdescribedcontactasbeingconversations,physicalcontactandphysicalpresenceandtheyperceivedchangesinsocialandemotionalwellbeingwhenpatternsofcontactvariedfromtheusual.

Mothersvaluedconversationsasameasureofwellbeingandthrough‘knowing’theirchildrentheyhaddevelopedastyleofcommunicationdependentonthesocialandemotionalwellbeingneedsoftheirchildren.Approachingtheirchildrenaboutdifficulttopicsorconcernstheyhadforthemsometimesrequiredtimebetweenconversations,anabsenceofcontact,togivetheiradolescentspaceandtimetothinkandprocess.Achangeinconnectionoverconversationwasfoundtobeanimportantmeasureorwellbeingformothers.“Iknowthechildrenarewellwhentheycanbothtellme,theirworriesandtheirsadnessandthingstheirangryabout,andalsowhentheycanprocessitwithmeandthencomeoutandmanageitattheotherend,sothattellsmethattheyaretravelingwell”Elizabeth

“Hernottalkingatall,Ithinkwouldbethehardestthing…Causereallyiftheydon’ttellyou,youdon’tknow,whetheryougetitfromsomebodyelse,andthenyouaskthequestions,butifshewouldn’ttellmeanything,thenIwouldbeconcerned”Heidi

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Participantsidentifiedtheneedforeachchildtohavetheirownphysicalspaceandidentifiedthisneedforspacechangeswithfluctuationsintheirsocialandemotionalwellbeingaswellasneedsvaryingbetweenchildren.Childrenwouldseekspacefromtheirparentsattimesofdistressorwouldseekouttheirparentsattimesofdistress;bothwereidentifiedbymothersduetothebehaviourbeingachangefromthenormfortheiradolescent.Physicaltouchwasidentifiedasimportanttowellbeing.Mothersdescribedtheirchildrenseekingtouchandthisbeinganindicatorofthemneedingthephysicalpresenceoftheirmother.Physicaltouchwasalsousedbytheparticipantsasaformofsupporttosocialandemotionalwellbeingwhentheirchildrenwerestrugglingpsychologically.

“Whentheyarecrankyitjustmeanstheyneedrelease,orsomething,whenshewaslittleshewouldgetreallycrankyandIwouldjustholdherthere,sojustholdher,welljustsqueeze,herlikenicetighthugs,soIstilldothatknow,sheisthesameperson,justabitbigger”HeidiMotherstalkedabouthowtheyperceivedthebehaviouroftheirchildrenandhowtheymeasuredperceptionofaproblembasedonchangeinbehaviourandthelengthoftime,ofthatchangeinbehaviour.

“ButIthink,it’sprobablythere’ssomethingaroundthatnottalkingandnothavingthatcloseness,thatyou,justthatsenseof,youknow,…heisquiteanaffectionatekidaswell,…andthewayhebehaveswithhis[siblings]aswell,Iguessifhewasn’tbotheringwiththemanymore,Imeantheyabsolutelyadorehimandheadoresthem,buttheyobviouslydoirritatehimquitealot,….Ithinkifwedidn’thavethat,thatcommunication,thatwouldworryme”BethThecarwasanidealenvironmentdescribedbymothers,wheretheycouldconnectwiththeirchildrenandhavethat‘contact’bothphysicallyandverbally.Participantstalkedaboutthisbeingvaluabletimewiththeiradolescents,withsomemanufacturingthiscontactandothersjustidentifyingitasqualityuninterruptedtimewiththeiradolescent.Mothersvaluedtheimportanceofmakingtimetoconnectwiththeirchildren.“ButInoticetooifwearedrivinginthecarandyouknowhimsittingalongsideofme,justchatting,thatisatimehemighttellmestuff,butIthinkyoudohavetohavesomesortoftimewiththemtoconnectwiththem,sothattheycantalktoyouaboutthings”Elizabeth Theliteraturesupportsthelinkbetweensocialandemotionalwellbeingorpreservinggoodmentalhealth,andindividualsneedingtofindspaceorhavingtimealone(4).Researchhasalsofoundthatparentsreportingoftheirchildren’sinternalisingproblemsandexternalisingproblems,eachpredictedtheperceptionthattheirchildhadaproblem(37).Thisliteraturecorrelateswiththeresearcher’sfindingsthatmothersmeasurewellbeingbasedontheirinterpretationofchangesintheiradolescentscontactwiththemandorotherfamilymembersandpeers. 

1.3 MakingConnections

Thethemeofmothersperceivingthattheyknowtheirchildrenwassupportedbytheparticipants’reflectionontheirownsocialandemotionalwellbeing.Mothersmade

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connectionsbetweentheirownbehaviourwhentheywereanadolescentandhowtheyrespondedtosocialandemotionalchallenges.Motherslearntfromwhatworkedfortheminthepastandwhatworkedforthemnow,tomanagetheirwellbeingneedsandusedthisknowledgetoidentifywiththeirchildren’sbehaviour.Participantsmadeconnectionstotheirchildrenthroughself‐reflection.

“IknowwhatIamlike,soifIamcrankyIwanttobeleftalone,soIjustdothat[leavehimalone]”Cara

“Wellsheisalotlikeme,soIkindofseelotsofhertraitsinmyselformytraitsinher”Heidi

Mothersmakeconnectionsbetweenwhattheywerelikeasanadolescentandwhattheyseeintheirchild’sbehaviourandrespondwithwhatworkedordidn’tworkforthemattheiradolescents’age.

“Ithinkitsmainlyfrommyexperiencesgrowingup,frommyexperienceswithmyfamily,mymumanddad.Yerbut,um,mainlyfrom,yourememberwhatyouwere[like]whenyouwereateenagerandIsortof,yougo,oktheyarenotgoingtotalktomeaboutthat,butmaybewecanopenthedoorandtalkaroundotherthings”Cara

Howtheadolescentsfathermanagedsocialandemotionalneedswasalsousedtoguidehowmothersperceivedknowingtheirchildren,astheycouldidentifysimilarbehaviourinthemselvesandortheirchild’sfather.Thesecomparisonsorconnectionsweresometimesdescribedasaconsciousprocessthatinvolveddiscussionswithothers,oftenthemothers’partner.Forothermotherstheseconnectionswereunconsciouswithmothersrespondingtotheirchild’sinternalisingorexternalisingbehaviourbasedonthefactthatthat’swhatworkedforthemorthatwaswhattheylikedorthoughtwasneededbasedontheirpersonalexperience.Mothersmadeconnectionsbetweenthemselvesortheirpartners’personalityintheirchildrenandthisinformedhowtheyperceivedtheiradolescentssocialandemotionalwellbeing.

“Myhusbandisquiteareservedman,whenitcomestoyouknowdeathandshowingyouremotions,[son]isverymuchlikehim,[daughter]isverymuchlikeme”Debbie

Bymakingtheseconnectionsmother’sperceptionofknowingtheirchildrenisstrengthened.Thisfindinghasnotbeennotedintheliteraturereviewedbytheresearcher.

2Theinfluenceofothers

Whenparticipantswereaskedabouttheiradolescentsocialandemotionalwellbeingandhowtheyperceivedthewellbeingoftheirchildren,theytalkedabouttheinfluenceofotherpeople.Thiswasthesecondmajorthematicarea.Mothersperceivedtheiradolescents’wellbeingwassupportedbyothersinthechild’snetwork,shapedbytheirchild’sengagementwithothersandmeasuredbytheirchild’sinteractionswithotherpeople.Participantstalkedabouttheimportanceoftheirchildren’sfriends,adultsintheircommunity(includingschoolteachers,tutorsandcoaches),family(highlightingsiblingsandgrandparents)andtheirchildren’ssurroundingpeergroups,whichinfluencedthem.

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Children’srolemodelsweretalkedaboutmysomemothersasbeingofbothpositiveandnegativeinfluencesonsocialandemotionalwellbeing.Allparticipantsalsotalkedabouttheroleofothers(suchaslike‐mindedfriends,teachersandothersadultswhocaredfortheirchildren)inhowtheyasparents,viewed,supportedandmeasuredtheiradolescentssocialandemotionalwellbeing.

Motherstalkedaboutthechangesofinfluencesandhowtheseinfluencesshapedtheirchildrenastheygrewolderandtherecognitionthatthemothersinfluencedecreasedandtheinfluenceofothersincreasedastheirchildrenwentthroughadolescence.Theinfluenceofotherswasbothpositiveandnegative.Inlateadolescentsoneparticipantspokeaboutherconcernandtherealisationthatshewaslosinginfluenceoverhersonandthattheinfluenceofothersfaroutweighedherinfluence.Herchild’swellbeingwasnolongersolelyinherhands.

“Apartofmeisalittlebitanxiousforthenextcoupleofyears,youknow!Iamstartingtogetalittlebit,ohmygod,thereisalltheseoutsideinfluencesonmyson”Grace

Anumberofparticipantsidentifiedadiverserangeofotherpeopleorthings(suchassport)thatinfluenced,maintainedandsupportedthesocialandemotionalwellbeingoftheiradolescentchildren.Mothersdidnotidentifyonesingleinfluencer,butratheridentifiedmany.

“He[son]hasgotverystrongviewsonsmokinganddrugsandstuff.Ithanktheschoolsforthat,obviouslywehaveputourlittlebitinthere,buthecertainlydoesn’tseeanythingathomeorinoursocialcircle,butyoualwaysworryaboutschool…Ithinkthesportmaybehelpingthat,thefactthatheisinsport”Alice

Mothersreflectedthattheiradolescents’interactionwithotherpeople,particularlyfamilymembers,wasanindicatorofhowwelltheyweredoingwiththeirsocialandemotionalwellbeing.Someparticipantstalkedaboutthechangesininteractionswithothersasbeingawayofmeasuringtheirchild’swellbeing.

“Heisveryforgivingwith[hissibling],[sibling]alwayspicksonhim,youknowbrotherlyloveandallthat,butyouknowwhenheisnotdealingwithlifetogreat,hehasn’tgotthetimetosortofplayandmuckaroundwith[hissibling]”Cara

Mothersperceivedthesignificanceoftheiradolescents‘fitting’inwithothers,suchastheirpeers,andidentifiedtheimpacttheybelievedthishadontheirchildren’swellbeing.

“Heisinyearsevenandthekidsarealltryingtodothecoolthing,soeventhoughitisfaketodothecoolthing,…it’s90%ofthepeoplethathehasgottospendthenextsevenyearswith,so[I]givehimafew,afewlittlebitsandpiecestomakehimlookabitcool,likehisblondandlonghairandhisripcurlwalletandallofhissockshavegotumQuicksilverorLeviwrittenonit,hisschoolshorts,IhavegothimonesthatsayVolcom…Idoalltheselittlethingsthat[son]wouldn’tpickorcareaboutandthenit’ssilly,butithelpshim,withthekidsthatarealldoingit”Ingrid

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Motherstalkedabouttheinfluenceothershadonhowtheyasparentsperceivedtheirchildren’swellbeing.Themothersperceptionwasinfluencedbyothersintheir(themothers)socialnetworks,influencefromcommunication(suchasfromschoolreportsandyearadvisors),influencefrompeopleintheadolescentsphysicalspace(suchassiblingsandgrandparents)andsport(suchascoachesandotherteammembers),allimpactingandhavingaroleinthesocialandemotionalwellbeingoftheiradolescentchildren.

Manyparticipantshighlightedthesignificanceofpeopleinpositionsofauthorityovertheirchildren,suchasteachersandcoaches,andidentifiedthemasasourceofsupport,adviceandinformationforthemselvesontheirchildren’ssocialandemotionalwellbeing.

“They[musicteacherandson]havebecomesortofgoodfriends.WhichandIhaven’tdiscouraged,becauseboysneedtohaverolemodelsandIhavealwayslikedthefactthatthereisanotherpersonthereifhehasaproblem,hecangoandtalktothem,ifhe’snotcomfortabletalkingto[Husband]andI…Soit’sjustanotherlittlecomforttoknowthereisanotherman”Cara

Mothersspokeabouttheimportanceofparentstalkingopenlyabouttheirconcernsfortheirchildren,sharingtheirconcerns,lookingoutforeachotherandsomespokeofthestrengthofasmallcloseknitcommunitywherepeoplecommunicated,andinfluencingtheirchildren’swellbeing.Oneparentsharedherroleasasupporterofotheradolescents’socialandemotionalwellbeingthroughherpositionasasportscoachtohighschoolagedstudentsandspokeofherperceivedroleinpassingonconcernsraisedbythestudentstotheirparentsandofthevalueofthisinformalrole.

“MyGirlfriend’sdaughterwashavingallthesedramaslastyearandyouknow,causeIcoachteenagers…..theywillcomehome[fromschooltopractice]andgo,‘ohmygosh,soandsoishaving,shewasteary,isshealright’andIwillringhermumandsay,‘sheishavingabadday’,andshewillsay,‘Ididn'tknow’,soyouknow,that’scommunicationinasmalltown…soIsupposeIamjustthatpersonthat,Iamnottheirparents…Isaytothemdon’ttellmeanythingIcan’ttellyourMumandDad…butmaybekidsneedthat[link],withoutdirectlysayinganythingtothem[theirownparents]”Heidi

Whilemothersidentifiedattimesthesupportingnatureofothers(suchasfriends,familyandthecommunity),somealsoidentifiedtheimportanceofremovingtheiradolescentfromotherswhentheyfelttheiradolescentchildwasvulnerable.Anumberofmothersmadereferencetoescapingfromsocietyandtheinfluenceofpeople,thestressofworkandtechnology,ifsomethinghappenedtomakethemworryoriftheiradolescentgotinto‘serioustrouble’.

“IfIwasreallyworriedabouthimIguesswewouldgocamping”Grace

Seeminglytoremovetheiradolescentsfromexternalinfluencesandreportedlyto“getbacktothebasicfundamentalsoflife”Fiona.AninterestingfindingconsideringtheresearchwasundertakeninaninnerregionalareaofAustralia,anareadefinedbyoneparentasbeing“closeknit”Heidi,anarearemovedfrommanysocialinfluencesseeninurbancentresandafindingnotapparentintheresearchers’reviewoftheliterature.Someparticipantshad

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drawnstrengthfromthiscloseknit,innerregionalareawhereasotherdescribeditsinfluencesasbeingnegative.Itishoweverdifficulttodetermineifmothersweretryingtoremovetheiradolescentsfromtheexternalinfluencesthatexistinanycommunityorspecificallythoseidentifiedasbeingfoundinasmallcommunitywherefamiliarityamongstcommunitymembersiscommon.

“Iremember[Husband]sayingifanyofthekidsevergetthemselvesintoserioustrouble,youknowwithdrugsorwithgangsordepression,hesaid‘Iwouldjustpackthatcar’andhesaid,‘wewouldjustgetinthatcarandwewouldjustdriveasfaraswecouldgetandcamponabeachorinapaddockorintheoutbackforaslongasittakestogetthembackontrack’”Fiona

Motherstalkedaboutsymptomsasbeingaresponsetoproblems(suchasgettingintothewrongcrowd,usingdrugsorbecomingdepressed),ratherthansymptomsbeingtheproblemsthemselves,andthereforereportedtheremovalofexternalinfluencesandtheisolationandopportunitytoexerttheir(theparents)influencestobetheanswertotheproblem,ratherthandirectlytreatingthesymptomasthecauseoftheproblem.Thatparentsarerespondingtoproblemsandnotidentifythemasbeingresponsestosymptoms,forexampleparticipantsdidnotanecdotallyidentifytheneedtotreat,forexampleanxiety,ratherchosetotreatthealcoholanddrugusethathasbeenaconsequenceoftheanxiety,seeminglybyremovingtheadolescentfromtheexternalinfluence,thoughttobethecauseoftheproblem.Thisfindingaroundmothersperceptionsofsymptoms,addsdepthtoSears(2004)(20)requestformoreresearchintohowyouthperceivesymptomsandhowtheydistinguishbetweensymptomsthatarepartoftheproblemitselfandsymptomsthatarearesponsetoaproblem.

Mothershadabroadviewoftheinfluencesofothersonmaintainingandsupportingmentalhealthiness,orwellbeing.Allparticipantshadnotsoughthelpfromaprivatepsychiatristorpsychologist,orbeenreferredtotheChildandAdolescentMentalHealthService(CAMHS)sowhenexploringtheroleofotherpeopleintheiradolescent’s’wellbeingitwasfromanon‐formalhelpseekingperspective,withmanyparentshypothesisinghowtheywouldrespondiftheybelievedtheirchild’swellbeingwasatrisk.RogersandPilgrim’s(1997)(4)researchparticipants,likethoseinthisstudy,alsohighlightedtheneedtoescape,howeverdescribedtheviewsonescapeasbeingthatofanindividualstrategytopreservementalhealth,unlikethisresearchweremothersdescribedescapeasbeingescapefrominfluencesontheiradolescentsandescapeasbeingcapturedtimebetweenadolescentandparent.

Theideaofpeopleinpositionsofauthoritysupportingchildren’ssocialandemotionalwellbeinghasbeenreflectedintheliterature(9).Researchershavefoundthatpeopleinpositionsofauthority,suchasparents,teachers,tutorsandcoacheswereabletoidentifywhattheybelievedtheycoulddotoensurethementalhealthofthoseintheircare,suchasbuildingself‐esteemandconfidence,respectingthem,beingpositiverolemodels,teachingvalues,moralsandsocialskills(30).Howeverthisstudydidnotexplorewhatthoseinpositionsofauthorityactuallydidtosupportthoseintheircareanddidnotexploretheroleofmonitoringthementalhealthofthoseintheircare,asdescribedbyanumberofmothersinthiscurrentstudy(30).

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2.1Gainingknowledge

Underthethemeof‘Theinfluenceofothers’,emergedthesubthemeofgainingknowledge.Thisincludedtheinfluenceotherpeoplehadonmothers‘frameofreference’,howtheyperceivedthattheyknewtheirchildrenaswellastheinfluenceofthemothersculturalandsocialpractices.Gainingknowledgeinvolvedthedesireofmotherstoaffirmorconfirmhowandwhytheyreactedincertainwaystotheirchildrenandhowtheyviewedtheirchildren’swellbeing.Somemothersusedothers(suchaslike‐mindedfriends,familymembersandcolleagues)toinformallyinvestigate,throughdiscussion,howtheywererespondingandmanagingtheirchildren’swellbeing.Motherstalkedofthesecomparisonsorinvestigationsasassistingthemtoidentifyhowtheyshouldrespondormanagedtheirchildrenaswellasgettingreassurancearoundhowtheyweremanagingdifficultieswiththeiradolescents’.

Mothersgainedknowledgeofwhatconstitutessocialandemotionalwellbeing,fromvarioussourcesandthroughvariousmeans.Participantsspokeofgainingknowledgethroughpracticeandmakingmistakes,throughreadingliterature,throughthemothers’vocation,throughtheirownexperienceswiththeirparentswhentheyweregrowingupandthroughcommunicatingwithothers,suchasfriends,familyandpeopleinauthorityovertheirchildren.Somemotherstalkedoflearningtojudgesocialandemotionalwellbeingthroughtalkingtootherparentsabouttheir(theparents)child'sbehaviour.Giventheimportancemothersplacedon‘knowing’theirchildren,somemotherstalkedofgainingtheknowledgethattheywantedtohear,seekinghelpandaffirmationoftheirthoughtsfromlike‐mindedpeople,peopleofsimilar‘cultural’beliefsandsocialpracticeorpeoplewhotheybelievedknewtheirchild.

“Iwouldgetadviceofffriendswho,youknow!Iwouldsay,wellwhatwouldyoudointhissituation?Ithinkthat’simportant,butobviouslylikemindedfriendswhoparentsimilarlyso,Iguessyouprobablyalreadyknowtheanswerbuttheyarejustreiteratingwhatyoualreadythink,becauseyouthinksimilarly.Itjustmakesyoufeelbetteraboutwhatyouhavealreadydecidedtodo,becauseyouarenotgoingtoasksomebodywhoparentscompletelydifferentlybecauseyouareprobablygoingtogo‘Ohthat’sabitoffthewallI’mnotgoingtodothat’”Fiona

Manymotherstalkedofgainingknowledgebyreflectingontheirexperiencesnowasadultsandinthepastwhentheywereadolescents.Mother’sknowledgeandexperienceofsupportinfluencedwhotheywouldturntoforsupportfortheirchildren.Theknowledgemothersgainedfrombothpositiveandnegativeexperiencesofhowtheypersonallyandhowothersaroundthem,managingtheirsocialandemotionalwellbeinginfluencedhowmotherssupportedtheiradolescentchildren’swellbeing.

“Causemymumisanadamant,youknow!Yougotoacounsellor,youdothisyoudothat,likeshewillalwaysdothat.WhereasIgo,ohIthinkyoucanbeconstructiveinotherways,youknowlike,don’tthinkwearethereyet,orwhatever.Mymotherhasmentalillnessandum,alwayshas…Iprobablyrebelagainstwhat’savailablebecauseofthat…that’swhyIprobablytryanddoeverythingself‐helpwise”Heidi

Mostmothersspokeofalackofformallearningaroundhowtosupporttheiradolescents.

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Mostparticipantsdidnotseekoutinformationorlearning.Theknowledgetheygainedwasoftenbychance.

“Isupposemostlyfromreading,readingstuff,andtheysendstuffoutwithlikeschoolnewslettersaswellsometimes.Sotheywillsendstuffoutabouttheinternetandbullying,and,Ijust,anythingthatisrelevant.Imaynotactuallygooutandsearchandsearchandsearchforthings,butifthingscomeacrossmypath,thenIwillreadthem”Beth

Mothersthatdidspeakofformallearningspokeofhowtheknowledgegainedthroughcourses,readingorthroughtheiremployment,wasnottheonlysourceoftheirknowledgearoundhowtoassisttheirchildren.Knowledgewasgainedthroughmanydifferentwaysandinvolvedmanydifferentpeople.

“Somuchofyourparentingcomesfromhowyouhavebeenparented,thebulkofit.Ihavelearntalotfrommyjob,youknowIamacounsellorwithchildren.Iworkwithparentsallthetime,soIhavelearntheapsfromthat.Buteventhen,Ihavealsobeenreallyheavilyinfluencedbyextendedfamilymembers,soauntsandunclesandhowtheyhaveparented,andIhavebeenveryluckyinthatIhavehadprobablymultiplefamilymemberswhohave,youknowparentedmeatdifferenttimes”Elizabeth

Thesefindingsproposeatransgenerationallinkbetweenattitudesandperceptionsofwellbeingandmentalillhealth,andthereforesuggesthelpseekingpatternsarelearntbehaviours,dependentonhowindividualsperceivetheirchildhoodoradolescentexperiencesofhelpseekingandthewellbeingofthosearoundthem.Otherhavehighlightedthepossibilityofthislinkintheirresearchbuthavenotbeenabletoevidencethelinkduetousingclosedquestionsintheirstudies(25).

Mothersdesiretoaffirmtheirthoughtsorreactionstotheirchildrenhasbeennotedintheliteraturebyothersasadesiretoboostonesmoraleandenhancementalhealthbyusingsupport,makingcomparisonsorseekingpositivefeedback(4).Afewmothersalsospokeofthestigmatheyhadabouthelpseekingpathwaysandsupportforsocialandemotionalwellbeing,howeverlittlehasbeenexploredintheliteraturearoundhowandwheretheseattitudesandthisknowledgehasbeengained.

2.2Support

Thesecondsubthemeundertheinfluenceofotherswasthatofsupport.Supportwasfoundtobemultifacetedwithmanyinteractiveinfluencesimpactingoneachmother’sconceptofsupport.Supportwasdescribedbymother’sasbeing;verbal,physicalandemotionalsupportfromotherpeopleintheparents’lifeaswellassupportthatmothersperceivedtheirchildrenfoundforthemselvesthroughphysicalactionsandthesupporttheyperceivedtheirchildrenreceivedfromotherpeopleintheirchild’slife.Thissupport,ofbothmothersandtheirchildrenwastalkedaboutasbeingofbothpositiveandnegativeinfluenceontheiradolescents’socialandemotionalwellbeing.Seekingsupportisamother’sandadolescentsfirststeptoinformalhelpseeking.

Pathwaystosupportwereshapedbymothersknowledge;theirpersonalexperiences,some

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motherschildhoodexperiencesandmotherssocialnetworks,bothpositivelyandnegatively,asoutlinedunder2.1Gainingknowledge.Allmothersinthisresearchhadnotseenchildandadolescentmentalhealthservicesorsoughthelpfromaprivatepsychologistorpsychiatrist,manyhadneverthoughtaboutwhotheywouldaccessiftheywereconcernedabouttheiradolescentssocialandemotionalwellbeing.Mother’stalkedwiththeresearcheraboutinformalhelpseekingandexploredwiththeresearcherforesightintotheiractionsiftheywereconcernedabouttheirsonordaughterssocialoremotionalwellbeing.Supportforsocialandemotionalwellbeingwastalkedaboutfromasocialperspective,notmedically,evenfromthosewhohadformaltraininginhelpingprofessions.Afewmotherstalkedaboutnotwantingpeopletojudgeor“label”theirchildrenwithpsychologicaldifficulties.

“Ididn’twanttoseekprofessionalhelp,becauseIdon’twant[son]tobelabelledasa,youknow,achildwithbehaviourissue.Becausetome,hedidn’thavebehaviouralissues,therewassomethinghewasn’thappyaboutinthathouse…”Beth

Allmotherstalkedabouttheireffortstobeself‐reliantwhenhelpseeking,seekingsupporttheirownpersonalwaywithoutaccessingformalprofessionalsupport.

“YouknowIthinkafishingtripwithamaleadultwouldprobablydojustasgoodasapsychologicalyouknow,appointment,andalabel.Ireallydon’twanttolabelhim,yer,Iwanthimtofindhisownway,howeverthatis”Grace

Mothersusedresourcestheywerefamiliarwith,somealsospokeoftheiradolescentchildrensourcingtheirownwellbeingsupports,suchaphysicalexercise,andinternetgamingortimewithfriends.Manyparticipantssupportedtheirfriends(whowerealsoparentsofadolescents)toaccesssupports,againthroughusingasocialperspective,sharingknowledgeofpastexperiencesofhelpseekingorhavingconnectionswithpeople,whoknewpeople,inthehealthservice.

Mostparticipantstalkedaboutapatternofinformalsupportnetworksthattheyaccessedorwouldaccess,iftheywereconcernedabouttheirchild’ssocialandoremotionalwellbeing.Thisstartedwithtalkingtotheiradolescentchild,thentopeoplewhotheyfeltknewtheirchildwell,theadolescents’fatherorstepfather,theirextendedfamilyandthenmovedontotheirschoolteachers,inparticulartheirchild’syearadvisororotheradultstheirchildrenhadcontactwith,suchastutorsandcoaches,andthentofriendsoracquaintancestheyfoundsupportive.

“Itwouldmorelikelybe[Husband]andItalkingforabit…thenitwouldbeMumandDad,ItalktothemalotifIhaveanyproblems.Theywouldprobablybethefirstperson,iftheyneededmorethanthat,anditwaslookinglikeIneededmoreofaprofessionalinputIwouldbeaskingquestionsaroundhere[communityhealthcentre],probablyevenum!Iknowthereisdifferentpeoplethattheboysaredealingwith.Theyhavemusiclessonsandtheyhaveareallygoodreportwiththeguysthatteachthemguitarandthat…Ifoundoutafewthingsabout[son]whenhewaslittlethroughtheguitarteacher”Cara

Manymothersdidnotwanttothinkaboutaccessingsupportsfortheirchild'swellbeinguntiltheyneededtoanddidnotidentifyfurtherlearningaboutadolescentwellbeingasa

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need.ParentswhenusingforesightdidnotidentifyGeneralPractitionersasasourceofsupportfortheiradolescentchildren’ssocialandemotionalwellbeing.OneparentthatdidmentionherGPdidsoinrelationtopersonallyknowingherGP.Motherperceptionthattheyknowtheirchildrenpresentedtostopthemfromgivingforesightintotheideathattheymayeverneedtoaccessformalsupportsofhelpseeking.

“Idon’tknow,Idon’treallyknowwhat’savailabletotellyouthetruth,Ireallydon’t.Iknowcommunityhealthisdowntheresomaybethereissomethingthere.ButIreallydon’tknowwhat’souttherebecauseIreallyhaven’thadtolook”Alice

“Ihaven’tactuallysoughthelpbecauseIdon’tthink,hehasn’tdoneanythingthat’soutofmy…notmyexpertise,butthatIhaven’tfelthelplessorthatIhaven’tbeenabletohandleorcontrol”Cara

Mentalhealthservicesweretalkedaboutbymanyparentsasbeingthelastresortforsupportandadvicearoundtheiradolescentchild’ssocialandemotionalwellbeing.Seekingprofessionalhelpwouldonlybeconsideredwhenallothersocialsupportshadbeenexhaustedandparentsfelthelplessoroutofcontrol.

“Itrytofixeverythingmyselfbefore[Igotomentalhealthservice],gottobeatrockbottomtogoandseekthat”Heidi

Thisisalsoreflectedintheliteraturewerehealthprofessionalswereseenasa“fallback”positionwhenlaynetworksandself‐reliancehadbeentriedandtested(4).Howevermothersthathadpersonalacquaintancesorfriendswhowerehealthprofessionalsreportedtheywouldaccessthesepeopleforsupportandadviceabouttheiradolescents,onaninformalbasis.Accessinghealthprofessionalsonaninformallevel,outsideofformalreferralpathwayswasviewedasbeingmoreacceptablebymanyparents.Theresearcherfound,asisnotedintheliterature,theimportanceof‘wordofmouth’andsupportivenessininnerregionalcommunities,tofacilitateaccesstomentalhealthcare,makingapparenttheimportantroleofinformalsupportstoaccessingappropriateserviceforadolescentswithsocialandemotionalwellbeingconcerns(38).

ThemajorityofmotherswhoparticipatedinthisresearchdidnotidentifyingGP’sasasourceofsupportforsocialandemotionalwellbeingneeds.Thisfindingwassimilartothatreflectedinliteraturethatfocusedonnon‐serviceusinglaypeopleandhelpseekingpopulationswhohadnotyetaccessedspecialistmentalhealthservices(4,13).ThoseintheliteraturewhohadreachedspecialistserviceviatheirGPhadbeenpromotedtodosobyothers(10).YettoaccessservicesinNSWundertheBetterOutcomeinMentalHealthCareprogramme,aimedtoimprovecommunityaccesstoqualityprimarymentalhealthcare,individualsmustfirstseetheirGPforassessment(16).Thisprimaryhealthcareprogrammedoesnotappeartobesetuptosupportyoungpeopletoaccessearlyinterventionnordidparentswhoparticipatedinthisstudy,reflectontheroleGP’shaveinsupportingpeopletoaccessservicesforsocialandemotionalwellbeingearly,beforetheneedforspecialistmentalhealthservices.

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Thehelpseekingpathwayparentshavetakenwiththeiradolescentchildreninmentalhealthservicesandparentsperspectiveonpathwaystoservicesafterbeingpresentedwithvignettesofyoungpeoplewithmentalhealthdifficultieshasbeenwidelystudied(9,16).Parentsuseofteachersatschoolforsupportandadvice(16)andtheresearchfindingsofmothersbeing“gatekeepers”totheirchildrenaccessingservices,hasalsobeenfoundinotherliterature(12)withthefindingsofthisqualitativestudygivingadeeperunderstandingtothereasoningbehindthis.Mothersseethemselvesasknowingtheirownchildrenandbeingthedecidersorthedriverstoseek,andfromwhomtoseeksupportfortheiradolescentchildren,whotheystillperceivetheyhaveinfluenceover.Motherschoosetodealwithproblemsthatarisebycognitiveingenuityandselectiveuseofsupportsfromothers;thishasalsobeenfoundintheliterature(4,20).

StrengthsandLimitations

Strengths:Tothebestoftheauthor’sknowledge,thisisthefirstqualitativestudyofnon‐serviceusingparentsofadolescents,thatexploressocialandemotionalwellbeing.ThestudywasundertakeninaninnerregionalareaofAustraliaandthereforeincludesapopulationofparentsthatarerarelyresearched.Veryfewqualitativestudiesintheareaofmentalhealthpromotionhavebeenfoundintheliterature.Thisstudywillprovideavaluablecontributiontotheliterature.

Limitations:Participantsvoluntarilyrespondedtovariousformsofrecruitmentstrategiesalltargetedatthegeneralpopulation,potentiallybiasingthesampletowardsrespondentswithpro‐socialattitudestohelpingothersandsharinginformation.Allparticipantsweremotherswhoworkedfullorparttimeand80%hadadolescentsons.Thismaylimitthegeneralizabilityofthefindingstoasmallgroupofparentswithsimilarcharacteristics.

DiscussionTheresearchfindingswillbediscussedfromtheperspectiveofamentalhealthprofessionalworkinginadolescentmentalhealthpromotionpreventionandearlyintervention.Themajorthemeof‘Mothersperceptionofknowingtheirchildren’,anditssubthemes,givepotentialunderstandingtowhymanyparentsdonotaccessformalsupportsorseekinformationaboutmentalhealthpromotion.Coulditbebecausetheysenseseekingformalsupportandinformation,asasignoffailure,duetotheinherentperceivedbelieftheyknowtheirchildren.Whenandifparentsdoapproachothersforsupportorothersidentifyconcernsforanadolescentundertheircareorauthority,thisresearchfindingmayassistthosetheyapproachtooffersupportandadvicewithaninformedsensitivityandempathy.

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Theresearcherfoundthatparentswerenotlookingoutfordiagnosticsymptomsnordidtheywanttothinkwithforesightintowhattheywoulddoiftheyhadconcernsfortheiradolescents’wellbeing.Theyspokeofdealingwithitwhenandifitoccurred.Thisfindinghassignificantimplicationsforengagingparentsinmentalhealthpromotion,preventionandearlyintervention.

IncreasingMentalHealthLiteracyMentalhealthpromotionispartofthesolutiontoimprovingmentalhealthliteracyandalthoughasindicatedfromtheresearchfindingsmothersaredifficulttoformallyengageinmentalhealthpromotion,amoreappropriatetargetgroupmothersidentifiedwasthoseinauthoritativeorteachingroleswiththeiradolescentchildren.Thequestionisthenaroundhowtoprovideandwhatinformationtoprovidepeoplesuchasschoolteachers,tutors,coachesandfamilyandfriendswith.MentalHealthFirstAid(MHFA)trainingneedstobeexploredasameanstomeetthisneed.Muchasthewayregularfirstaidprovidestechniquestorespondtoaphysicalhealthcrisis,MHFAhelpsindividualsidentifyandrespondbothtoadevelopingmentalillnessandapsychiatriccrisis(39).MHFAalsoprovidesagreaterandmorecompassionateunderstandingofmentalillnessandhasbeenadaptedtomeettheneedsofvariouspopulationsincludinganadolescentversion,YouthMentalHealthFirstAid(YMHFA)targetingpeoplewhocareforyouth.YMHFAisanevidencebasedprogramdeliveredbyaccreditedinstructorsthatisrapidlyspreadingworldwide,withitsdevelopersaimingforthetrainingtobecomeascommonasregularfirstaidwithMHFAcertificatesbecomingarequirementformanyprofessionsthatprovidehumanservices(39).TheAustraliangovernmenthasalreadyrecognisedthemeritsofthistraining,withtheGovernmentfundingMHFAtraining,targetingfrontlinecommunityworkersinthefinancialandlegalsectors,relationshipcounsellorsandhealthcareworkers,targetingthoseinsectorswhointeractwithpeopleinfinancial,legalorrelationshipcrisiswhereriskofsuicideisincreased(40).CollaborativelyworkingwithschoolsMental health services and Education services need to work collaboratively to supportadolescentmentalhealth.Asthemothersinthisstudyhaveindicated,teachersandschoolsareseenasbothasupporttosocialandemotionalwellbeingfortheiradolescentchildren,aswell as a deterrent. Promoting this identified role of teachers and schools, to supportwellbeingisessentialtosupportparentsintheircaregivingroleasmonitorsandsupportersof their adolescents’ social and emotionalwellbeing. Teachers job demands can constraintheir roles in a school and the pressures of keeping up to datewith changing curriculumrequirements can make the idea of additional responsibilities of monitoring a student’swellbeing seem overwhelming. If mental health services move more towards workingcollaborativelywithschoolsratherthantakingontheroleofdictator(providingservicestoschoolsorprovidingservicetoschoolstudents),schoolsmayviewthisasacommitmentandan investment by health services, therefore putting more energy into building acollaborativerelationshipwithmentalhealthservices.

U n h e a r d V o i c e s : N o n – s e r v i c e u s i n g m o t h e r s p e r c e p t i o n s o f t h e i r a d o l e s c e n t s ’ s o c i a l a n d e m o t i o n a l w e l l b e i n g .

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Therearevariouswaysmentalhealthprofessionalsandservicescanreview their roles inschools.SchoolcounsellingservicesareavailabletoallschoolstudentsinNSWgovernmentschools,howevertheiravailabilityininnerregionalareasislimited,withtimebeingfocusedon assessment of students learning andbehaviour, addressing theneeds of studentswithdisabilities and learning difficulties. Mental health services need to work with existingservicestoreviewtheirmodelsofcareandtoworktoengageparents,especiallymothersina‘population’basedmentalhealthpromotioncampaign.MindMattersistheleadingnational‘whole‐school’mentalhealthinitiativeforsecondaryschools,assistingschoolstobuildtheircapacity to promote and protect the mental health, resilience and social and emotionalwellbeing of their students and school community(41). MindMatters is currently beingrevisedwiththeAustralianGovernmentDepartmentofHealthcommissioningthedeliveryand rollout to all schools nationally(41). There is a need to revise mental health servicedesign to reflect the Mental Health Action Plan (2013‐ 2020), targeting prevention andpromotingmentalwellbeing,byresourcingserviceswithlowerentrycriteriasothatmentalhealthservicesarenotseenasthe“lastresort”forparentswhenlookingforsupportaroundsocialandemotionalwellbeing.PathwaystomentalhealthsupportMentalHealthprofessionalsarebeingbasedincommunityhealthcentres,youthfocusedcentressuchasHeadspaceandmorerecentlyinGeneralPractices.Thismodelishoweverbasedonexisting‘psychiatric’or‘clinicalpsychologicalframeworks’withoutresearchingtheunderstandingoftheordinary,non‐serviceusingpopulationwithnohistoryofidentifiedmentalillness.Thisresearchgivesavoicetothepopulationwhoareparentsofadolescents.Mentalhealthpoliciesandprogramsneedtofocusnotonlyontheneedsofpeoplewithdefinedmentaldisorders,butalsotoprotectandpromotethementalwellbeingofallpeople.Recognisingthereisanimportantroleinlookingatprotectivefactors,particularlyforchildrenandadolescentsandtheimportanceofpromotingmentalhealthandpreventingmentaldisorder.

MothersinthisstudydidnotrecognizingGP’sasasourceofhelporadviceforsocialandemotionalwellbeing,howeverthisishowthegovernmenthassetupservicestoassistthegeneralpopulationinAustralia,accessearlyinterventionthrough‘BetterAccess’mentalhealthplansorsharedcarearrangementscoordinatedbytheirGP’s.Motherswillapproachotherlaypeopleintheirsocialnetworkortheirchild’s‘learning’network(throughschool,tutorsorcoaches),whoareoftennotequippedtoidentifyorsignposttomoreappropriatementalhealthsupportservices(39).Motherswillwaittillasituationbecomesextremeordetrimentaltoanadolescencefunctioningbeforespecialistsupportisconsidered,potentiallyinfluencingthelongtermoutcomesoftheiradolescent’smentalillhealth.Thegeneralpopulationcancontactthelocalmentalhealthaccesslinehoweverthisappearstohaveaverylowpublicprofile,notbeingmentionedbyanyoftheparticipantsinthisstudyandreferralcriteriatothissecondarymentalhealthservicehasaveryhighthreshold,nottargetingearlyinterventionorprevention.Ifservicesaregoingtopreventmentalillhealth

U n h e a r d V o i c e s : N o n – s e r v i c e u s i n g m o t h e r s p e r c e p t i o n s o f t h e i r a d o l e s c e n t s ’ s o c i a l a n d e m o t i o n a l w e l l b e i n g .

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andpromoteandencourageearlyinterventionforsocialandemotionalwellbeingparentsneedtobeawareoftheservicesthatdoexistandservicesneedtobetargetedtoengageparentsandcarersattheirlevel,usingparentsunderstandingofsocialandemotionalwellbeing.Mentalhealthprofessionalswhomhavetheskillsandknowledgearoundmentalhealthpromotion,preventionandearlyinterventionarecurrentlyseenbyparentsasthelastresortforhelpandsupport.Thisisinkeepingwiththecurrentservicedesign,basedonamedicalmodelofhelpseeking,withsecondaryservicesonlytreatingthosewithdiagnosablementalillnesses.Weneedtofocusourattentiononwhoparentsarecurrentlyturningtoforsupportandadviceifwearetoengageparentstoincreasetheirtrustandknowledgeinearlyintervention,preventionandpromotionofadolescentmentalhealth.RecentyouthmentalhealthservicedesigninAustraliahasfocusedonimprovingadolescents’accesstoservices.ServicessuchasheadspacehavebeendesignedbyTheNationalYouthMentalHealthFoundationaimingtoenhanceprimarymentalhealthcareforyoungpeopleaged12‐25years(42).Headspace,aCommonwealthfundedinitiativewassetuptoprovideyouthfriendly,easilyaccessibleandeffectiveservices,prioritisingmildtomoderatementalhealthissues,anareaofcarenotcurrentlyservicedthroughsecondarymentalhealthservices(42).Headspacefocusontheadolescentandofferinformationtoparentsandcarersontheirwebsiteabouttalkingtotheiradolescentaboutmentalhealthconcernsandaboutaccessingservices.Howevertheresearcher’sfindingsindicatethatnon‐serviceusingmothersdonotidentifyservicesasinformationsourcestosupportthedecisionstheymakearoundtheiradolescentchildren’ssocialandemotionalwellbeingneeds.Informalhelpseekingfrompeoplethatknewtheirchildren,suchasschoolteachersoryearadvisers,orfrompeoplewhomthemotherstrustedandrespected,suchastheirparents,partneroralike‐mindedfriendwasthemostcommonidentifiedsourceofsupportformothers.Thiswouldsuggestthatyouthfocusedservicessuchasheadspacearenotmeetingtheneedsofmothersofadolescents,themaingatekeepersofyoungpeopleaccessingservicesandthepeopleadolescentsmostfrequentlyaccess,secondtotheirfriends,forsupportandadvice(21).Theareaofmentalhealthpromotionandpreventionneedstofocusonengagingthepeoplethatmothersintheresearchidentifiedintheirinformalpathwaystosupportandcare.FutureResearch

Theparentsinthisstudydescribeaninherentunderstandingoftheirchildren.Thisisnotaphenomenawidelyresearchedintheliteratureasitisdifficulttocaptureandtomeasure,duetoitsinvisiblepathicnature.Thisfindingsuggeststhatparentsbelievetheycouldidentifydifficultieswithsocialandemotionalwellbeingbasedontheirinherentknowledgeoftheirchildren.Thisraisesthequestionofhowaccuratetheirmeasuresofsocialandemotionalwellbeingare,comparedtohowtheiradolescentchildrenandmentalhealthprofessionalsviewtheirwellbeing.Furtherresearchdirectlycomparinghowparentsandtheiradolescentchildrenmonitorandmeasuresocialandemotionalwellbeingmayaddadeeperunderstandingtothisfindingintheresearchandmaybetterinformtheeducationalneedsofparentsandmothers.

U n h e a r d V o i c e s : N o n – s e r v i c e u s i n g m o t h e r s p e r c e p t i o n s o f t h e i r a d o l e s c e n t s ’ s o c i a l a n d e m o t i o n a l w e l l b e i n g .

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Mothersplacedcriticalimportanceontheperceptionofknowingtheirchildren,raisingquestionsofhowthisknowledgeisderivedandquestionsaroundtheimplicationsthisfindinghasonparentsandcarersofadolescentchildrenwhomareadoptedorincare.Mothersusedtheirknowledgetounderstandanddeterminethattheirchildrenweremanagingtheiremotionalandsocialwellbeing.

Formentalhealthprofessionalstobeaccessibletoparentsandsupporttheearlyphaseofhelpseeking,policymakersneedtodirectresourcestocatertotheneedsofthegreaterpopulation,withservicesbeingfundedtolowertheirentrycriteriatoprovidesupportandadvice,andexploringvariationsfromthemedicalmodelofcasemanagementwiththeidentifiedclientbeingtheparentorcarernotjusttheadolescent.Takingnotefromtheresearchfindingtotargetsupportandadviceattimeswhenmothershaveidentifiedtheywantadditionalsupport,suchaswhentheirchildrenaresuspendedforthefirsttimeorattimesoftransitionatschool.MentalHealthPromotionPreventionandEarlyInterventiontargetingparentsneedstolooktoengageparentsonaninformallevel,tobuildtrustandarelationshipwithparents.Servicealsoneedtofocusonprovidinginformationtothepeoplethatparentsidentifytheygotoforsupportandadviceabouttheiradolescentssocialandemotionalwellbeing.

ConclusionNon‐serviceusingmothersdonotseethesocialandemotionalwellbeingoftheiradolescentchildrenasatickboxratingscale,measuringmentalhealthormentalillhealth.Mothersdescribewellbeingas‘knowing’theirchildrenandmostbelievethattheycanidentifysocialandemotionalwellbeingneedsandcouldidentifyifsomethingwasgoingwrongfortheirchild.Motherswereableto‘know’theirchildbecauseoftheemphasistheyplacedontherelationshiptheyandtheirpartnerhadwiththeirchildren,identifyingtheimportanceofthisrelationshipinbeingableto‘read’theirsonsordaughtersandbeingabletorespondtotheirwellbeingneeds.Thisperceptionofknowingtheiradolescentwasdevelopedthroughspendingtimewiththeirchildren.Mothersthroughtheprocessof‘knowing’theiradolescentchildrenwereabletomeasuretheirchild’swellbeingbythepresenceorabsenceofcontacttheirchildrenhadwiththemorthosearoundthem.Parentsidentifiedchangeasasignthatfurtherexplorationoftheirchild’swellbeingwasneeded.Thisexplorationwaspredominantlyundertakenbymothers.

Whenmeasuringorexploringtheiradolescentchildren’swellbeing,andmakingdecisionsonhowtomanagetheirconcerns,mothersmadeconnectionstotheirownwellbeingneeds.Mothersmanageddifficultiesbymakingconnectionswiththeirownexperiencesandhowtheydealtwiththeminthepastandinthepresentmoment.Forsomemothersthismeantmakingconnectionsbyreflectingandlearningfromwhatworkedwellforthemwhentheywereanadolescent,aswellasgainingknowledgefromwhatdidnotworksowellandbehaviourtheywouldnotfollowwiththeirownfamily.Mothersalsomadeconnectionsbetweentheiradolescent’sbehaviourandthebehavioursoftheadolescent’sfatherandsiblings,usingtheseconnectionstomeasurewellbeingandtomakedecisionsonhowtorespondtowellbeingneeds.

U n h e a r d V o i c e s : N o n – s e r v i c e u s i n g m o t h e r s p e r c e p t i o n s o f t h e i r a d o l e s c e n t s ’ s o c i a l a n d e m o t i o n a l w e l l b e i n g .

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Mothersofadolescentspresenttobethegatekeepersforadolescentsseekinghelpandsupport.Mothersviewedtheirroleaspivotalinsupporting,monitoringandmentoringwellbeing,yetalsodescribedtheimportanceoftheroleofotherpeopleinsupportingthemtoprovidethissocialandemotionalsupport.Otherpeoplewerealsoseenbymothersasinfluentialontheiradolescents,supportingthem,influencingthem(whetherthatbepositivelyornegatively)andengagingandshapingwhotheywereandhowtheyreactedtolifeanditsstressors.Mothersdidnotbelievethattheyhadalltheanswerstomeetconcernsthatmayariseintheirchildrenandcouldidentifyvariouswaystheygainedknowledgetosupporttheiradolescentchildren.Theyreliedonothersclosetotheiradolescentchildrenincluding,teachers,yearadvisors,tutors,coachesandotheradultsinvolvedwiththeirchildrentogainknowledgeabouttheirchild’swellbeing.

Mothersdidbelievethattheyshouldbeabletofindthesupportthattheirchildrenneededormayneedinthefutureandgainedsupportforthemselvesaswellastheirchildrenthroughinformalhelpseekingpathways.Mothersusedinformalsupportsonaregularbasis,talkingtothefatheroftheirchild,talkingtotheirparentsandtofemalepeers,whotheyfeltparentedinasimilarway,lookingforreassuranceandadvice.Motherswoulddoallthattheycouldtosupporttheiradolescentchild,withsomesuggestingtheywouldremovetheirchildcompletelyfromexternalinfluencesifmajorconcernsarose,optingtogoremotecamping.Motherswouldonlyseekprofessionaladvicefortheiradolescents’socialandemotionalwellbeingconcerns,whentheyhadexhaustedallotherinformaloptions,whentheyfelthelpless,whereforcedtoorfeltthattheyhadlostcontrolofthesituation.Unlesstheirchildwasexperiencing‘bigtrouble’theywouldnotlooktoseeksupportoradvicefromprofessionalsupportservices.

Thisresearchgivesvoicetothelargegroupofparentswhoarenotcurrentlyusingservices,helpingtodevelopasharedunderstandingofwhatworksfortheminpromotingtheirsonordaughterswellbeing.Thefindingsgiveusrichinformationthatcanguidefuturepolicyandservicedesigntosupportmentalhealthpromotion,preventionandearlyinterventionforadolescents.

RecommendationsTheresearchfindingssuggestthemajorityofthepopulation,non‐helpseekingparents,arenotgoingtovoluntarilyaccessmentalhealthpromotionservicesintheircurrentdesign,forsupportoradvice.Mentalhealthpromotion,preventionandearlyinterventionservicesneedtoexploredifferentwaysofengagingparentsofadolescentsandneedtofocusontheinformalsupportnetworksmothersinthisresearchidentifytheyalreadyuse.Theresearcherrecommendsthefollowingoutcomesfromthisstudy;

TheNationalProgramStandardsforTeachers,responsiblefornationallyconsistentaccreditationofinitialteachereducationprograms,needstoendorseallteachereducationprogramstoincludeevidencebasedtraininginadolescentmentalhealth.Aimingtoincreaseallnewgraduateteachersmentalhealthliteracy.Trainingneedstoincluderaisingawarenessofteacher’srolesasperceivedbyparentsandstudents,theirroleinidentifyingmentalillhealth,managingmentalhealthneedsinthe

U n h e a r d V o i c e s : N o n – s e r v i c e u s i n g m o t h e r s p e r c e p t i o n s o f t h e i r a d o l e s c e n t s ’ s o c i a l a n d e m o t i o n a l w e l l b e i n g .

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classroomandreferralpathways.SuchevidencebasedprogramsasYMHFAshouldformthebasisofthistraining.

Thoseresponsibleforteacher’scontinualprofessionaldevelopment(Theboardofstudiesteachingandeducationstandards(BOSTES)inNSW)needtoendorseYMHFAandmakeevidencebasedtrainingsuchasthisanessentialrequirementundertheteacher’saccreditationpolicy.Thiswouldensureallteachershaveawarenessandskillstomanageadolescentsandtheirfamily’smentalhealthneeds.

Makereadilyavailableevidencebasedadolescentmentalhealthtrainingtokeystakeholderswhosupportadolescents.Localcouncilsneedtobackcommunityorganisationstosupportthesocialandemotionalwellbeingofadolescentsintheircare.Thiswouldincludethoseincoachingandtutoringroleswhoareoftennotmembersofprofessionalassociationswithcodesofethicsandcontinuingprofessionaldevelopmentstandards.SuchsupportmaybegainedthroughmeanssuchasClubGrantstoprovidefreeornominaltrainingeventstargetingsportscoachesandprivatetutors,promotingtheirkeyroleinsupportingandprovidingadviceforadolescentswhomaybevulnerabletohavingdifficultieswiththeirsocialandemotionalwellbeing.YouthMentalHealthFirstAidmaybeonesuchcourseappropriateforthisgroup.LocalMentalHealthServiceswouldneedtosupportandguidethisinitiative.

Increasethenumberofmentalhealthprofessionalsembeddedinschools.TheDepartmentofEducationandCommunitiesneedstoworkinpartnershipwithTheDepartmentofHealthandtheMinisterformentalhealthandageing,todevelopandimplementapilotprojectthatexplorestheroleofadolescentspecialistmentalhealthprofessionalsbeingbasedinhighschools.Theseworkerswouldformpartnershipswitheducationprovidersandcommunity,helpingcreateawholeschoolapproachtobuildingresiliencethroughmentalhealthpromotionandprogramssuchasMindMatters,aswellasbeingactivelyinvolvedinpreventioninitiativesandactingquicklywhenmentalillnessisevident.Thementalhealthprofessionalwouldbeavailablenotonlyforstudentsbutforparentsandcarerstoo,providingaplaceforparentsandcarerstofindoutwhattheycandotosupporttheirchildrenandtogetsupportthemselves.Forthismodeltoeffectivelyengageparentsandcarersmentalhealthprofessionalswouldneedtofocusonestablishinformalandformalconnectionswithparentsandcarers,asthegatekeeperstoadolescentsaccessingsupportservices.Theschoolbasedmentalhealthprofessionalwouldworktoengageparentsandcarersatcriticaltimessuchasthetransitionstohighschool,entryintosenioryears,parent’steachersinterviewsandsuspensionplanning.

Futureresearchneedstovalidateparents’perceptionthattheyknowtheirchildren.Thismaybemeasuredbycomparingadolescentself‐ratingofsocialandemotionalwellbeingwithparentsratingoftheiradolescents’socialandemotionalwellbeing.Withoutthesedirectcomparisonsitisdifficulttosaythatparents’perceptionsarepredominantlyaccurateorinaccuratemeasuresoftheiradolescentchildren’ssocialandemotionalwellbeing.

Furtherresearchneedstoexploretheimplicationsofadolescentsocialandemotionalwellbeingbeingmeasuredbyparents‘pathic’knowledgeofperceivingthatthey

U n h e a r d V o i c e s : N o n – s e r v i c e u s i n g m o t h e r s p e r c e p t i o n s o f t h e i r a d o l e s c e n t s ’ s o c i a l a n d e m o t i o n a l w e l l b e i n g .

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knowtheirchildren.Areplicastudyusingapopulationofnon‐biologicalparentsorcarersofadolescentsmayderivefurtherknowledgeoftheimplicationsofthisphenomenonon‘problem’recognition.

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mentalhealthproblems.AdvancesinMentalHealth.2013;11(2):131‐42.11. WilsonRL,CruickshankM,LeaJ.ExperiencesoffamilieswhohelpyoungruralmenwithemergentmentalhealthproblemsinaruralcommunityinNewSouthWales,Australia.ContemporaryNurse:AJournalfortheAustralianNursingProfession.2012;42(2):167‐77.12. BroadhurstK.Researchreview.Engagingparentsandcarerswithfamilysupportservices:whatcanbelearnedfromresearchonhelp‐seeking?Child&FamilySocialWork.2003;8(4):341‐50.13. SayalK,TischlerV,CoopeC,RobothamS,AshworthM,DayC,etal.Parentalhealth‐seekinginprimarycareforchildandadolescentmentalhealthconcerns:qualitativestudy.TheBritishJournalofPsychiarty.2010;197:476‐81.14. SteelZ,SiloveD,McDonaldR,SandfordP,HerronJ,BaumanA,etal.Pathwaystothefirstcontactwithspecialistmentalhealthcare.Australian&NewZealandJournalofPsychiatry.2006;40(4):347‐54.15. ZwaanswijkM,VerhaakPFM,BensingJM,vanderEndeJ,VerhulstFC.Helpseekingforemotionalandbehaviouralproblemsinchildrenandadolescents.EuropeanChild&AdolescentPsychiatry.2003;12(4):153‐61.16. JormAF,WrightA,MorganAJ.Beliefsaboutappropriatefirstaidforyoungpeoplewithmentaldisorders:findingsfromanAustraliannationalsurveyofyouthandparents.EarlyInterventioninPsychiatry.2007;1(1):61‐70.17. WilsonCJ,RickwoodD,DeaneFP.Depressivesymptomsandhelp‐seekingintentionsinyoungpeople.ClinicalPsychologist.2007;11(3):98‐107.18. RickwoodDJ.Promotingyouthmentalhealth:prioritiesforpolicyfromanAustralianperspective.EarlyInterventioninPsychiatry.2011;5:40‐5.19. WorldHealthOrganisation.TheMentalHealthActionPlan2013‐2020.WorldHealthOrganisation,2013.

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Appendix One 

Media Release Date (TBA)

TAREE STUDY TO DISCOVER HOW PARENTS SUPPORT TEENS New research launched in Taree today will uncover how parents discern between normal adolescent behaviour and behaviour that might suggest their teenager needs further emotional or mental health support. Taree Youth Mental Health Occupational Therapist Lauren Vaughan is calling on parents to be part of the study to help mental health workers understand more about the very early stages of mental health problems. “We know from past research that teenagers are most likely to ask their parents for support if they have emotional and social wellbeing concerns,” Ms Vaughan said. “However, we don’t know much about how parents provide that support and what they do to help their teenager.” “I’m interested in find out from parents about how they manage things at home with their teenagers,” Ms Vaughan said. “What kinds of conversations do they have with their teenagers about emotional and social wellbeing? Importantly, how do parents identify when a difficulty is more than just a normal part of adolescent behaviour, and something that needs further support.” The research findings will help mental health workers understand how they can support parents to identify mental health issues earlier, so young people can get access to help as soon as possible. Ms Vaughan is interested in talking to volunteer parents of teenagers aged between 12 and 17 years living in the Greater Taree City Council area. The private, in person interviews will take about one hour and can be arranged at a mutually agreeable time and place. All personal information will be kept private, and in any information included in the research report will be kept anonymous. There are no financial or other rewards for participating in this study. Ms Vaughan is being supported by the Health Education and Training Institute as part of the Rural Research Capacity Building Program. If you are interested in participating or would like to find out more about the project please contact the researcher, Ms Lauren Vaughan, on (02) 6539 6300. Media Enquiries: Emma Gibbs on 6767 7137 (HNE- xxxx) Hunter New England Local Health District – Communication & Stakeholder Engagement Unit Tel 02 4985-5522 Fax 02 4921-4969 A/Hours 0418 463 031 Email communication@hnehealth.nsw.gov.au healthdirect AUSTRALIA – providing expert health advice 24 hours a day to NSW residents – Tel. 1800 022 222

U n h e a r d V o i c e s : N o n – s e r v i c e u s i n g m o t h e r s p e r c e p t i o n s o f t h e i r a d o l e s c e n t s ’ s o c i a l a n d e m o t i o n a l w e l l b e i n g .

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Appendix Two 

How do parents describe the

emotional and social wellbeing of their adolescent children?

Chief Investigator: Lauren Vaughan Forster Community Health Centre Youth Mental Health Project Officer Manning Mental Health 16 Breese Parade Forster NSW 2428 Ph: 6539 6300 Fax: 6554 8874 (Version Three25/06/13)

ParticipantInformationSheetYouarebeinginvitedtoparticipateinaresearchstudyinvestigatinghowparentsdescribeemotionalandsocialwellbeingintheiradolescentchildren.ThestudyisbeingconductedbyLaurenVaughan,anOccupationalTherapistworkingforHunterNewEnglandLocalHealthDistrictwiththeYouthMentalHealthProjectintheManningarea.Itisimportantthatyouunderstandthepurposeoftheresearchstudyandwhatyourparticipationwillinvolve.Pleasetakeyourtimetoreadthefollowinginformationandaskquestionsyoumayhave,ordiscussfurtherwiththeresearchteamoryourfamily/friendsbeforeagreeingtoparticipate.Whyistheresearchbeingdone?Thisstudywillexplorehowparentsdescribesocialandemotionalwellbeingfortheyoungpeopleintheircare.TheResearcherwantstotalktoparentswhohavenothadanycontactwithChildandAdolescentMentalHealthServicesfortheirchildren,togainagreaterunderstandingofwhattheyseeascharacteristicsanddifficultiesfortheiradolescents.Theresearcherwantstolearnmoreaboutthelanguagethatparentsusetodescribeemotionalandsocialwellbeing.Theobjectivebeingthatwiththisin‐depthunderstanding,professionalswillhavealanguagetousewithparentsthatwillinformmentalhealthpromotiontopicsthatarecentredonwhatparentsidentifyasimportantemotionalandsocialwellbeingissuesforadolescents.Byfocusingonthepeoplethatarecaringandsupportingadolescentsinourcommunity,theresearcherwishestomeaningfullyengageparentsandtoguidefuturementalhealthpromotion,preventionandearlyinterventioninitiativestargetedatparents.Whocanparticipateintheresearch?

U n h e a r d V o i c e s : N o n – s e r v i c e u s i n g m o t h e r s p e r c e p t i o n s o f t h e i r a d o l e s c e n t s ’ s o c i a l a n d e m o t i o n a l w e l l b e i n g .

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Youhavebeeninvitedtoparticipateinthisresearchstudybecauseyouareaparentofanadolescentaged12‐17years.Anyparentwithachildovertheageof18isexcludedfromtheresearch.ParentswhohavehadorcurrentlyhavechildrenseenbytheChildandAdolescentMentalHealthServiceoraprivatepsychiatristorpsychologistwillnotbeabletoparticipateinthestudy.YourparticipationIfyouagreetoparticipate,youwillbeinvitedtoattendasingle,facetofaceinterviewwiththeresearcher,whichwilllastapproximatelyonehour.Theinterviewwilltakeplaceinalocationmutuallyagreedbetweentheresearcherandyourself.Youwillbeencouragedtochoosealocationwhereyoufeelcomfortableandwhereyourprivacycanberespected.Duringtheinterview,youwillbeaskedquestionsaboutyourexperiencesasaparentofanadolescentandwhatyouseeasissuesthatimpactonyouryoungperson’semotionsandsocialwellbeing.Youarenotrequiredtoansweranyorallofthequestionsaskedofyou.Youmayasktoskipanyquestionthatmakesyoufeeluncomfortableorthatyoudonotwishtoanswer.Theinterviewwillbeaudiorecordedandyoumayaskforthetapetobestoppedandsectionsofiteditedorerased,atanytimeduringtheinterview.Youmayalsoaskfortheinterviewtostoptoallowyoutotakeabreakandtheinterviewcanberesumedwhenyouareready.Youwillbeofferedacopyofyourinterviewtranscript.Youmayatanytimeduringtheinterview,orduringtheresearchperiodwithdrawfromthisstudywithoutgivingareason.Therearenorepercussionsfornotparticipatingorwithdrawing.Ifyouhaveanyconcernsregardingthispleasediscusswiththeresearchernow.Benefitsandrisksofparticipating.Theinterviewwillincludesometopicswhichmaybesensitive,suchasdiscussingyourfeelingsandemotionsaboutyourson(s)andordaughter(s).Ifyoufindthatyoubecomeinanywaydistressedbyanyofthetopicsdiscussedorbyyourparticipation,thiscanbediscussedwiththeresearcher.Thereisarangeofservicesavailabletoprovidesupport,suchasCarersAssist,Lifeline,websitessuchasYouthBeyondBlueandHeadspace,yourlocalGeneralPractitionerandthelocalMentalHealthService.Everyonewhoparticipantsinthisresearchstudywillbegivenwritteninformationonvarioussourcesoffurtherinformationandsupportonthistopic.Howwillyourprivacybeprotected?Thefacetofaceinterviewwillbeaudiorecordedusingadigitalvoicerecordersothattheresearchercanfocusonthediscussionratherthantakinglengthynotes,andtoensurethattheresearcherisaccurateinrecordingyourresponses.Youmayaskfortherecordertobeturnedoffatanytimeduringtheinterview.Theaudiorecordingwillbetranscribedverbatim(wordforword)bytheresearcherandthenstudied/analysed.Yournamewillnotberecordedontheaudiorecordingandyournameandanyidentifyinginformationwillnotbeassociatedwithanypartofthewrittenreportoftheresearch.Allofyourinformationandinterviewresponseswillbekeptanonymous.Onlytheresearchernamedabovewillhaveaccesstoyouridentifiableresponsesandwillkeepallofyourinformationanddatainasecure(passwordprotected)locationforaperiodof5years.Theonlyinstanceswhenconfidentialitymaybebrokenwouldbeiftheintervieweridentifiesthatyouoryourchildrenareatriskofabuseorneglect.Ifconcernsareraisedduringtheinterview,theresearcherwillattempttoraisethesewithyoubeforeseekingfurtherassistancefromthechildprotectionservices.Themandatoryreportingofconcernsrelating

U n h e a r d V o i c e s : N o n – s e r v i c e u s i n g m o t h e r s p e r c e p t i o n s o f t h e i r a d o l e s c e n t s ’ s o c i a l a n d e m o t i o n a l w e l l b e i n g .

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tothewelfareofchildrenisaNSWMinistryofHealthPolicythatallhealthprofessionalsaremandatedtofollow.Howwilltheinformationcollectedbeused?Itisplannedthattheresultsofthisstudywillbepublishedinpeerreviewedprofessionaljournalsandmaybepresentedatconferences.Asummaryoftheresultsoftheresearchstudywillalsobeprovidedtothelocalmediaforpublication.Noneoftheinformationincludedinthereportwillbeabletoidentifyyou.Youwillbeofferedacopyofyourinterviewtranscript.Ifyouwouldliketoreceiveacopyoftheresultsofthestudypleaselettheresearcherknowandacopywillbeprovidedattheconclusionofthestudy.FundingParticipationinthestudywillnotcostyouanythingotherthanyourtimeandyouwillnotbepaidforyourparticipationinthestudy.ThestudyisbeingsponsoredbytheRuralDirectorateoftheHealthEducationandTrainingInstituteaspartoftheRuralResearchCapacityBuildingProgrambyallowingtheresearchertimetocompletethestudy.Nomoneyorfinancialpayment,otherthantheresearcher’susualpay,isbeingmadedirectlytotheresearcher.Whatdoyouneedtodotoparticipate?Whenyouhavereadthisinformationsheet,theresearcher,willdiscussitwithyouandansweranyquestionsthatyoumighthave.Ifyouhaveanyquestionsorconcernsatanystage,pleasedon’thesitatetocontacttheresearcher.Ifyouwouldliketoparticipateinthisresearchstudy,pleasereadtheattachedparticipantconsentformandcontacttheresearcherLaurenVaughanonthedetailsabove.Atimewillthenbemutuallyarrangedforyoutomeetwiththeresearcherforaninterview. Ifyouhavecomplaintsorconcernsaboutthisresearch?ThisresearchhasbeenapprovedbyHunterNewEnglandHumanResearchEthicsCommitteeofHunterNewEnglandHealth(Reference13/05/15/4.08).Shouldyouhaveconcernsaboutyourrightsasaparticipantinthisresearch,oryouhaveacomplaintaboutthemannerinwhichtheresearchisconducted,itmaybegiventotheresearcher,or,ifanindependentpersonispreferred,toDrNicoleGerrand,Manager,ResearchEthicsandGovernance,HunterNewEnglandHumanResearchEthicsCommittee,HunterNewEnglandHealth,LockedBag1,NewLambtonNSW2305,telephone(02)49214950,emailHnehrec@hnehealth.nsw.gov.au.ChiefInvestigator:LaurenVaughanOccupationalTherapistYouthMentalHealthProjectOfficerManningMentalHealthHunterNewEnglandLocalHealthDistrict

Thisinformationsheetisforyoutokeep.Thankyoufortakingthetimetoconsiderparticipatinginthisresearchstudy.

U n h e a r d V o i c e s : N o n – s e r v i c e u s i n g m o t h e r s p e r c e p t i o n s o f t h e i r a d o l e s c e n t s ’ s o c i a l a n d e m o t i o n a l w e l l b e i n g .

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Appendix 3 

How do parents describe the emotional and social wellbeing of their adolescent children?

Chief Investigator: Lauren Vaughan Forster Community Health Centre Youth Mental Health Project Officer Manning Mental Health 16 Breese Parade Forster NSW 2428 Ph: 6539 6300 Fax: 6554 8874 (Version Two: 30/04/13)

Participant Consent Form

I _______________________ (your name) agree to participate in this research project and give my consent freely.

In giving my consent to be a part of the research and I agree and understand that: 1. I have read and understood the Participant Information Sheet and have had the opportunity to discuss the research and my involvement in the project with the researcher, Lauren Vaughan. I am satisfied that any questions that I have had about the project have been answered. 2. I consent to participate in a single, face to face interview regarding my experience as a parent of an adolescent. I understand that this interview will be audio recorded and that I am able to request the interview and/or audio recording to stop or cease at any time during the interview. 3. I consent to the audio tape of my interview being transcribed (word for word) and understand I will be offered a copy of the transcription. 3. I understand that my participation in this research is completely voluntary and that I am not under any obligation to consent. 5. I understand that I can withdraw from the research at any time during the research period and do not have to give any reason for withdrawing. 6. I understand that my information and interview responses will be treated with strict anonymity and stored securely (password protected) in accordance with ethical research standards. 7. I understand that the interviewer, as a mandatory reporter, has the lawful responsibility to identify and report children, young people and/or unborn children who are at risk of significant harm from abuse or neglect. 8. I understand that the data and findings from this research project may be published and that any potentially identifiable information will not be used in any reports.

Name of Participant:_____________________

Signature of Participant: _____________________ Date:___________________

I have informed the above person about the research and answered any questions he/she had.

Signature of researcher: ______________________

Name of researcher:__________________________

Occupational Therapist

Chief Investigator Date:___________________

U n h e a r d V o i c e s : N o n – s e r v i c e u s i n g m o t h e r s p e r c e p t i o n s o f t h e i r a d o l e s c e n t s ’ s o c i a l a n d e m o t i o n a l w e l l b e i n g .

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Appendix Four 

InterviewSchedule‐VersionTwo“Aconversationwithpurpose”(Smithetal,2012)

Introductions:Introducemyselfandthankthemagainforagreeingtoparticipate.EnsureParticipantConsentFormissigned.ExplainthatIwillberecordingtheinterviewandmaytakenotes.Informtheparticipantthattheymaystoptheinterviewatanytime.Inlinewithinterpretivephenomenologytheresearcherisusingasemistructuredinterview,withquestionspromptingadialoguebetweenparticipantandtheinterviewer.Initialquestionsmaybemodifiedinlightofresponsesthroughouttheinterviewprocess.Belowisaresearchinterviewguidetoprompttheparticipanttoensuretheresearchobjectivesaremeetbytheresearcher.Remindtheparticipantthattheyhaverespondedtomyrequestofwantingtoknowmoreabouthowparentsdefineemotionalandsocialwellingissuesintheiradolescents.WhattheyidentifyasEmotionalandSocialWellbeing“Researchhasfoundthatadolescentsaremostlikelytoasktheirparentsforsupportiftheyhaveemotionalandsocialwellbeingconcerns.Canyoutellmeabitabouthowyouseeemotionalandsocialwellbeinginyourfamily?”“Whatkindsofbehaviourwouldyousaydefine/describegoodemotionalandsocialwellbeing?”(usingpromptssuchas“Canyoutellmeabitmoreaboutthat?”“Couldyouexplainwhatyoumeanby….”“Whatmakesyousaythat…”togainamorein‐depthunderstandingoftheirresponses.)DescribingDifficulties“Whatkindsofthingswouldyoulookoutforifyourconcernedtheyhavehadabaddayoraren’ttravelingsowell?”(mayusethewordsEmotionalandSocialWellbeingdependingonparentsresponsetopreviousquestions).Furtherprobesmaybe“Whydidyouthinktheyreactedlikethat?”,”Howdidyoureactwhen……..”“Whatwasitabouthis/herbehaviourthatmadeyoureactlikethat…?”Dependingonresponsefromabove;UnderstandingConcernsandresponses“Howdoyoufigureoutwhetheryourson/daughtersbehaviourisjustpartofbeinganadolescentorifitssomethingmoreserious?”“Asaparentwhatsignsdoyoulookfor,whatcausesyouconcern?”.“Whatweretheydoingorsayingthatmadeyouthinkthat”.Furtherprobingmaybe“Whydoyouthinkthat’s(behaviour)important/significant(usetheparentslanguage)?”“whatdoyouusuallydoifyourconcernedabout……….(adolescentsname)?”“Howdoyoutalkto(approach)yourson/daughteraboutconcernsyouhaveforthem?”,“Howdoestheconversationstart?”.Dependingontheparticipantsresponsesquestionssuchas“Canyoutellmeaboutatimewhenyouwereworriedyourson/daughterdidn’thavetheirheadintherightplace?”“whatpromptedyoutothinkthat?”maybeasked.Iftheyidentifythattheyhavemanagedaseriousissueaskhowtheyrespondedtothat,howdidtheyreact,”whatdid

U n h e a r d V o i c e s : N o n – s e r v i c e u s i n g m o t h e r s p e r c e p t i o n s o f t h e i r a d o l e s c e n t s ’ s o c i a l a n d e m o t i o n a l w e l l b e i n g .

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itfeellikewhen…”,“tellmemoreaboutwhathappened?”.“Hasanything(or“wouldanything”)prompt/edyoutothinkabouthowyoureact?”ManagingEmotionalandSocialWellbeing“Hasthereeverbeenatimewhenyoufeltyouneededmoreinformationorfurthersupport?”Whodidyouturnto?”Whatwereyoulookingfor?”“Whereyouhappywiththeresponseyougot?”“Howdidithelpyouornot?”Askparticipantsquestionsaroundseekingsupportoradvicearoundconcernsfortheirson/daughter/children.Askiftheyhaveeversortoutadviceorsupportforsomethingtheyfelttheyneededmoreinformationon.Theinterviewmayusetheprompts“whatpromptedyoutodothatorhowdidyoudecidethatwasthebestthingtodo?”“Didyoufindthehelp/advice/supportyouwerelookingfor?”“Tellmemoreaboutwhathappened”.Headingshavebeenusedabovetoassisttheresearchertoensuretheobjectivesoftheresearchasmet.Notallquestionswillbeaskedofeachparticipant.Participantsthemselveswillleadthediscussionreflectingontheiraccount.