Prevalence and Correlates of Anxiety, Depression, Perceived Stress, and Post-Traumatic Stress Symptoms in Parents with Adolescents in Residential Treatment

ABSTRACT

Previous studies have suggested that parents with adolescents in residential treatment (RT) may struggle with their own mental health. However, few have comprehensively described parents’ mental health using valid and reliable measures and examined parent mental health in reference to other contextual factors that may be intertwined and intervenable. Therefore, the purpose of this exploratory study was to describe the perceived stress, symptoms of anxiety and depression, and post-traumatic stress disorder (PTSD) in parents with adolescents in RT in the United States. This cross-sectional study included a sample of parents (N = 71) with adolescents in RT. On average, parents reported elevated depressive symptoms, moderate stress, mild-to-moderate anxiety symptoms, and subthreshold PTSD symptoms. However, there were differences in mental health based on gender, race, ethnicity, adolescent living location, and adolescent psychiatric diagnoses (e.g., bipolar, depressive, and substance use disorders). Findings provide a more comprehensive description of parents’ mental health during the RT admission, underscoring the bidirectionality of parent-adolescent mental health and well-being.

Practice Implications

• Parent mental health screening and treatment may be necessary because of elevated depressive symptoms, anxiety, and stress

• Parent stress is chronically elevated across the treatment trajectory, highlighting the need for parent preparation, support, and stress management

• Assessment of trauma and social support is needed because PTSD scores were higher in unpartnered parents

• Parent and adolescent mental health is bidirectional and providing treatment and support to parents benefits adolescents

KEYWORDS:

• Parent
• mental health
• residential treatment
• residential care
• child welfare
• behavior problems

While most adolescents with mental health and behavioral disorders reside in the community for treatment, approximately 55,000 children and adolescents reside in residential treatment facilities (RT; NCSL, 2020). RT facilities are secure facilities where adolescents temporarily reside to receive 24/7 supervision and intensive, individualized mental health treatment (AACAP, 2016). Studies that examine profiles of adolescents at intake describe youth as presenting with a range of psychosocial, psychiatric, and academic challenges (Griffith et al., 2009; Trout et al., 2008). On average, youth who reside in RT engage in more frequent and intense high-risk behaviors (e.g., delinquency) and exhibit greater behavior problems (80.3% vs. 68.6%) and attachment issues (69.8% vs. 43.4%) compared to youth residing in the community (Briggs et al., 2012). Compared to their peers in other types of care (e.g., foster care), adolescents in RT tend to exhibit more severe and pervasive behavior problems (Leloux-Opmeer et al., 2016), with externalizing behaviors being the most common reason for referral (Theall et al., 2021).

The Role of the Family in Treatment Gain Maintenance

Despite presenting with a myriad of challenges at intake, adolescents tend to make treatment gains while in RT (Lanier et al., 2020; Preyde et al., 2011b; Trout et al., 2010). Trout and colleagues (2010) evaluated data from 640 youth discharged from RT and found that, on average, youth showed no clinically significant internalizing or externalizing behaviors at discharge. These findings are consistent with a study by Theall et al. (2021), who tracked treatment gains in 2,053 youth, finding that youth improved in social engagement, hyperactivity, and distractibility. While research demonstrates that adolescents can learn adaptive strategies, maintaining these gains in the community has proven challenging and essential for long-term success. Engaging the family unit and, in particular, the primary caregivers (e.g., parents) in treatment is essential for positive treatment outcomes (Huefner et al., 2015).

Parents may struggle with their mental health because the demands of parenting an adolescent with severe and pervasive mental health needs are stressful (Buchbinder & Bareqet-Moshe, 2011; Harder et al., 2018). Upon their adolescent’s admission to RT, parents often experience ambivalent feelings of loss, grief, and relief (Buchbinder & Bareqet-Moshe, 2011; Herbell et al., 2020; Tahhan et al., 2010). Grief can be accompanied by perceptions of incompetence and failure as parents (Buchbinder & Bareqet-Moshe, 2011; Herbell et al., 2020; Tahhan et al., 2010). To cope, parents may suppress emotions and isolate, leading to hopelessness, shame, and anger (Buchbinder & Bareqet-Moshe, 2011; Herbell et al., 2020). When adolescents are discharged from RT, parents’ emotions tend to shift from despair toward anxiety because of the high stake nature of discharge in this population (Hess et al., 2012; Patel et al., 2019; Preyde et al., 2019). With more parent support and education, the anxiety surrounding the discharge process may be alleviated (Patel et al., 2019; Herbell & Breitenstein, 2020).

Parent Mental Health

Overall, parents with adolescents in RT are chronically distressed and may struggle with their mental health either as a chronic condition or as an acute reaction to their circumstances (Briggs et al., 2012; Griffith et al., 2009; Leloux-Opmeer et al., 2016). There are varied prevalence rates of mental illness reported in parents with adolescents in RT ranging from 30% to 70% depending on the facility type and gender of the parent (Baker et al., 2005; Griffith et al., 2009; Stage, 1999). Importantly, these statistics do not reflect the parents who have suspected diagnoses or parents who exhibit subclinical symptoms. One group of researchers examined relationships among parental psychopathology, parenting stress, quality of life, and parenting quality in a Dutch sample of parents with adolescents in RT (Harder et al., 2018). Their findings support that 70.3% of parents (n = 45) exhibited psychopathology, with the highest prevalence being depression (54.7% mother and 39.1% father), anxiety (29.7% mother and 12.5% father), and substance dependence (14.1% mother and 26.6% father; Harder et al., 2018). However, this study did not report the range of symptoms (e.g., subclinical, elevated), nor did it examine PTSD, which may be important to capture given the high degree of stress and adversity (Briggs et al., 2012; Buchbinder & Bareqet-Moshe, 2011; Patel et al., 2019).

Griffith et al. (2009) conducted an archival review of admission data (N = 566) from one large RT facility in the United States. Results suggest that some families displayed high-risk behaviors, including substance abuse (51%), inappropriate discipline that was too lenient or harsh (47%), abandonment (42%), and neglect (39%). Interestingly, parent mental health was among the least common risk factors (24%; Griffith et al., 2009). While the Griffith and colleagues (2009) study provides valuable insight into some of the risk factors and behaviors in this population, there are limitations in the mental health measures used. Specifically, the lack of validated mental health measures may lend to the under-reporting of mental health symptoms and does not allow insight into this population’s specific mental health challenges.

Taken together, research is abundant regarding the challenges that adolescents in RT experience, including the maintenance of treatment gains (e.g., educational achievement, restrictiveness of discharge placement; Preyde et al., 2011b; Ringle et al., 2012; Robst et al., 2013). However, significantly less is known about their parents. Previous studies have suggested that family function is a key issue in this population (Sunseri, 2004; Sunseri, 2020) and that parents may struggle with their mental health (Baker et al., 2005; Griffith et al., 2009; Harder et al., 2018) and parenting stress (Harder et al., 2018). However, few have assessed parent mental health symptoms using valid and reliable measures and examined parent mental health in relation to contextual factors that may serve as intervention targets. The purpose of this exploratory study was to expand upon previous literature by determining the prevalence of perceived stress and symptoms of anxiety, depression, and PTSD in a sample of parents with adolescents currently and previously in RT. In addition, every family has a unique structure and inner workings based on broader contextual factors such as culture (e.g., ethnic, racial, and socioeconomic) and member characteristics (e.g., number of children and marital status). These contextual variables are complex and interact with one another to shape the development of family members, which extends to the presence or absence of mental health symptoms for parents and adolescents. To provide a more comprehensive understanding of parent mental health, we examined parent mental health in reference to adolescent and parent contextual factors, which allows for identifying strengths and challenges.

Methods

Design

This cross-sectional study used a descriptive correlational design to determine associations among parent and adolescent contextual factors and parents’ mental health symptoms (depression, anxiety, PTSD, perceived stress). The University Institutional Review Board approved this study, and all parents provided informed consent.

Sample

Parents were included in the study if they were at least 18 years old, resided in the United States, and identified as a parent (biological, kin, adoptive, foster, step) to an adolescent aged 12 to 17 with a mental health or behavioral disorder. To be eligible, parents self-reported that their adolescent previously (past year) or at the time of the study resided in an RT facility in the US. Using convenience sampling, we recruited parents through Facebook. Our team developed a study-specific Facebook page to join parent and mental health-oriented Facebook groups. Each time we joined a group, we contacted the group’s moderator and asked permission to post a virtual study recruitment flyer. On the recruitment flyer was a link that sent potential parents to a study landing page that housed study information, eligibility questions, the consent form, and study measures. Parents who completed the survey were compensated with a $20 gift card.

Data Collection

All study procedures, including recruitment, eligibility screening, informed consent, and data collection, were conducted virtually with all data collected in Qualtrics (Qualtrics, 2021). First, parents completed a comprehensive demographic assessment of parent and adolescent contextual information. Parent demographic information included age, sex, race and ethnicity, income, education, marital status, and employment status. Adolescent demographic information included age, sex, race and ethnicity, and psychiatric diagnoses.

Study Measures

Depressive symptoms were measured using the 4-item PROMIS Depression Short Form 4a (PROMIS; Pilkonis et al., 2011). The PROMIS is designed to measure the emotional symptoms of depression rather than somatic symptoms such as changes in sleep or diet (Pilkonis et al., 2011). The short form of the PROMIS is a validated measure with items found in the 28-item PROMIS (Pilkonis et al., 2011). Parents responded on a 5-point scale to the degree to which depressive symptoms were present in the previous week (1 = never to 5 = always). The possible total scores ranged from 4 to 40, with higher scores indicating greater depressive symptoms. The PROMIS has demonstrated excellent internal consistency (α = .96; Kaat et al., 2017) and constructed validity with the DSM-5 criteria for depression (Pilkonis et al., 2011).

Anxiety symptoms were measured using the 7-item General Anxiety Disorders questionnaire (GAD-7; Spitzer et al., 2006). Parents respond on a 4-point scale to the degree to which their anxiety symptoms were reflected in the previous 2 weeks (0 = not at all to 3 = nearly every day). Total scores range from 0 to 21 and are calculated by summing the scores on items. A score of 10 or higher on the GAD-7 represents a reasonable cut point for identifying cases of GAD (Spitzer et al., 2006). The cut points of 5, 10, and 15 are interpreted as representing mild, moderate, and severe anxiety levels (Spitzer et al., 2006). The GAD-7 has demonstrated a good internal consistency (α = .89; Löwe et al., 2008) and diagnostic criterion validity with the DSM-IV GAD diagnosis (Spitzer et al., 2006).

Symptoms of PTSD were measured using the Primary Care PTSD Screen for DSM-5 (PC-PTSD-5; Prins et al., 2016). The instrument begins with a single item that assesses exposure to a traumatic event (e.g., serious accident, and abuse). If the parent denies exposure, the total score is zero. However, if a parent indicates that they have experienced a traumatic event, the parent is then directed to complete five additional yes or no questions about how the event has affected them over the past month. Total scores range from 0 to 5. The PC-PTSD-5 has exhibited good test–retest reliability (r = 0.83), and in validation testing, a score of 4 or greater is sensitive to probable PTSD (Prins et al., 2016).

Perceived stress was measured using the 9-item Brief Inventory of Perceived Stress Scale (BIPS; Lehman et al., 2012). Parents responded on a 5-point scale (0 = never to 4 = very often) how frequently they perceived stress in the past month. The BIPS categorizes stress into three groups: lack of control, pushed, conflict, and imposition. One item is reverse coded. Total scores range from 0 to 36, with higher scores indicating greater perceived stress (Lehman et al., 2012). Using cut scores from the Perceived Stress Scale (Cohen et al., 1983), a score of 11 or less is considered lower than normal perceived stress, a score of 12 to 23 is moderate perceived stress, and a score of greater than 24 is considered higher than average perceived stress. The BIPS has good internal consistency (α = .85; Lehman et al., 2012) and demonstrates concurrent validity with the Perceived Stress Scale (Lehman et al., 2012).

Data Integrity

Following Pozzar et al.’s (2020) guidance, we developed a data integrity protocol to screen for illegitimate and automated responses. According to the data integrity protocol, each survey response was screened for fraudulent and suspicious indicators. Fraudulent indicators included survey responses that were less than 10 min or duplicate or unusual responses. Suspicious indicators included nonsensical responses or responses that included text similar to the recruitment flyer or survey question. This analysis did not include responses if they had one fraudulent indicator or at least three suspicious indicators (Pozzar et al., 2020). As an added protection, we used Qualtrics-enabled features such as reCAPTCHA and ballot box stuffing prevention. Before implementing the data integrity protocol, there were 100 responses. After removing suspected illegitimate responses, the final sample size was 71 parents.

Data Preparation

Parent and adolescent race categories were collapsed due to small counts, so that Asian, Native Hawaiian, Pacific Islander, American Indian, and Alaska Native were combined and other and missing races were combined. Adolescent living location was coded into five categories: residential treatment, group home or foster care, home or friend/relative home, inpatient psychiatric treatment, and other (e.g., shelter care). Parent education levels of less than a high school and a high school degree or equivalent were combined. Parent income was coded into five categories: 0–39,999, 40,00–59,999, 60–79,999, 80–99,999, and 100k and above. Parent employment status categories of disabled or retired were combined. Parent marital status was coded into two categories: unpartnered and partnered.

Adolescent diagnoses were aggregated into nine groups: (1) Neurodevelopmental and neurobehavioral disorders (e.g., Autism and ADHD), (2) Schizophrenia spectrum and other psychotic disorders, (3) Bipolar and depressive disorders (e.g., depression and mood disorders), (4) Anxiety-related disorders, (5) Trauma and stress-related disorders (e.g., attachment disorder), (6) Substance abuse disorders, (7) Obsessive-compulsive and related disorders (e.g., eating disorders), (8) Disruptive, impulsive-control, and conduct (e.g., oppositional defiant disorder), and (9) Personality disorders.

Data Analysis

Data were described using frequency (percentage) for categorical variables and median (interquartile range) for continuous variables. There were four outcomes related to parent mental health: Brief Inventory of Perceived Stress (BIPS) score, GAD-7 Anxiety (GAD) score, PROMIS Depression score, and Brief PTSD score. For categorical predictors, differences by group in each of the four outcomes were evaluated with the Kruskal–Wallis test. For each continuous predictor, separate univariable linear regression models were constructed for each of the four outcomes. P-values < 0.05 were considered statistically significant. All analyses were conducted using R version 4.0 (R Core Team, Vienna, Austria).

Results

Description of Parent Characteristics

Parents (N = 71) were a median age of 48 years old with an interquartile range from 40 to 51 years old. Three-quarters of parents (n = 53) identified as female, with the majority (n = 60, 85%) identifying as biological parents. Most parents (n = 59, 83%) retained custody, while their adolescent was in RT. The median number of children who were ever in RT was two with an interquartile range between one and three. See, Table 1 for a description of parent demographics.

Table 1. Parent Demographics N = 71.

Characteristic	N (%)	Characteristic	N (%)
Age (Median, IQR)	48 (40–51)	Education
Gender		Less than HS/HS degree	4 (6)
Female	53 (75)	Some college with no degree	5 (7)
Male	18 (25)	Associates degree	6 (9)
Race		Bachelor’s degree	29 (41)
Asian, NHOPI, AIAN	6 (9)	Graduate degree	27 (38)
Black or African American	11 (15)	Household Income ($)
More than one race	3 (4)	0–39 K	8 (11)
Other/unknown	1 (1)	40–59 K	8 (11)
White	50 (70)	60–79 K	12 (17)
Ethnicity		80–99 K	7 (10)
Hispanic or Latinx	6 (9)	100 K+	36 (51)
Relationship to adolescent		Employment Status
Adoptive parent	11 (16)	Disabled or retired	3 (4)
Biological parent	60 (85)	Unemployed not looking	13 (18)
Marital Status		Unemployed looking for work	6 (9)
Partnered	61 (86)	Employed part-time	12 (17)
Unpartnered	10 (14)	Employed full time	37 (52)
Number of Children in RT (Median, IQR)	2 (1–3)	Custody Maintained	59 (83)

IQR = interquartile range; NHOPI = Native Hawaiian and other Pacific Islander; AIAN = American Indian or Alaska Native

Description of Adolescent Characteristics

Adolescents were a median age of 15 years old with an interquartile range of 13–17 years old. Slightly over half of adolescents were females (n = 37, 52%). At the time of the study, less than half of adolescents lived in an RT facility (n = 26, 37%). The largest group of adolescents resided at home or a friend/relative’s home; however, 12 adolescents lived in “other” locations, including boarding school, substance use treatment, and college. See, Table 2 for a description of adolescent demographics.

Table 2. Adolescent demographics N = 71.

Characteristic	N (%)	Characteristic	N (%)
Age (Median, IQR)	15.0 (13 −17)	Age Symptoms Started (Median, IQR)	10.0 (5–13)
Gender		Parent-Reported Adolescent Psychiatric Disorders
Female	37 (52)	Neurodevelopmental//Behavioral Disorders	35 (49)
Male	34 (48)	Schizophrenia Spectrum & Psychotic Disorders	3 (4)
Race		Bipolar & Depressive Disorders	48 (68)
Asian, NHOPI, AIAN	4 (6)	Anxiety & Related Disorders	43 (61)
Black or African American	13 (18)	Trauma & Stress-Related Disorders	15 (21)
More Than One Race	5 (7)	Substance Abuse Disorders	12 (17)
Other/unknown	7 (10)	OCD & Related Disorders	20 (28)
White	42 (59)	Disruptive, Impulsive-Control & Conduct Disorders	7 (10)
Ethnicity		Personality Disorders	5 (7)
Hispanic or Latinx	6 (9)
Current Living Location
Residential treatment	26 (37)
Group home or foster care	2 (3)
Home or friend/relative home	29 (41)
Inpatient psychiatric treatment	2 (3)
Other	12 (17)

Note: Parents could select more than one adolescent psychiatric disorder; IQR = interquartile range; NHOPI = Native Hawaiian and other Pacific Islander; AIAN = American Indian or Alaska Native.

Associations among Contextual Factors and Parent Perceived Stress

In the following sections, only significant results will be discussed. Please see Table 3 for the complete listing of relationships examined and associated p-values. The median perceived stress score among parents was 20 (moderate), ranging from 8 to 31. The median stress score was the highest among parents with adolescents in the “other race” group and lowest among parents with adolescents who were more than one race (25 vs. 13, p =.033). There were no significant associations between adolescent living location and perceived stress. However, compared to adolescents living in RT facilities to adolescents living anywhere else, there was a significant association between adolescents’ living location and parents’ perceived stress (p = .045). The median perceived stress score was higher in parents whose adolescents were currently living in an RT facility than parents whose adolescents were not currently living in an RT facility (22 vs. 17). There was a significant association between parent race, ethnicity, and perceived stress (p = .013). The median perceived stress score was the highest among parents in the “other race” group and lowest among parents of more than one race (25 vs. 13). The median perceived stress score was higher among parents who were not Hispanic or Latinx than Hispanic or Latinx parents (21 vs. 14, p = .003).

Table 3. Relationships between contextual factors and parent mental health.

	Perceived Stress	Anxiety	Depression	PTSD
	p-value	p-value	p-value	p-value
Adolescent Contextual Factors
Gender	0.8	0.4	0.007*	>0.9
Race	0.033*	0.9	0.6	0.3
Ethnicity	0.067	0.4	0.4	0.5
Living Location	0.063	0.7	0.2	0.4
Living in RT	0.045*	0.6	0.5	0.8
Custody Status	0.2	>0.9	0.6	0.2
Age	0.8	0.9	0.5	0.3
Age at Onset	0.6	0.5	0.9	0.2
Parent Contextual Factors
Gender	0.2	0.9	0.10	>0.9
Race	0.013*	>0.9	0.6	0.5
Ethnicity	0.003*	0.2	0.2	0.8
Marital Status	0.8	0.2	0.2	0.002*
Relationship to Adolescent	0.6	0.12	0.4	0.7
Income	0.5	0.7	0.6	0.8
Education	0.095	.089	0.12	0.8
Employment Status	>0.9	0.7	0.7	0.2
Age	0.7	0.3	0.2	0.2

Associations among Contextual Factors and Parent Anxiety

The median anxiety score among the sample of parents was 7.5 (mild to moderate) with a range of 0 to 21. We tested associations among parent-reported adolescent diagnoses (e.g., Neurodevelopmental/Behavioral Disorders) and parent mental health outcomes (see, Table 4). Median anxiety scores were higher among parents whose adolescents were diagnosed with substance use disorders than parents whose adolescents were not diagnosed with substance use disorders (12 vs. 7, p = .020). The median anxiety score was higher in parents with adolescents diagnosed with bipolar and depressive disorders than parents whose adolescents were not diagnosed with bipolar and depressive disorders (8 vs. 6, p = .043). The median anxiety score was lower in parents with adolescents diagnosed with disruptive, impulsive-control, and conduct disorders than in parents whose adolescents were not diagnosed with disruptive, impulsive-control, and conduct disorders (4 vs. 8, p = .016).

Table 4. Associations between diagnostic categories and parent mental health.

Parent-Reported Adolescent Psychiatric Disorders	Perceived Stress		Anxiety		Depression		PTSD
	Median (IQR)	p	Median (IQR)	p	Median (IQR)	p	Median (IQR)	p
Anxiety and related disorders
Yes	21 (17–24)	0.2	8 (5–11)	0.6	10 (8–12)	0.6	1 (0–3)	0.10
No	16 (14–24)		7 (5–10)		9 (5–12)		0 (0–1)
Bipolar and depressive disorders
Yes	21 (16–25)	0.071	8 (6–12)	0.043*	11 (7–13)	0.019*	0 (0–3)	0.3
No	15 (14–21)		6 (5–8)		8 (4–10)		0 (0–1)
Disruptive, impulsive-control, and conduct disorders
Yes	17 (16–19)	0.3	4 (2–6)	0.016*	6 (4–8)	0.025*	1 (0–2)	0.9
No	20 (15–25)		8 (6–12)		10 (7–12)		0 (0–3)
Neurodevelopmental, cognitive, and behavioral disorders
Yes	17 (15–24)	0.3	8 (5–10)	0.9	10 (7–12)	0.7	0 (0–3)	0.4
No	22 (16–25)		7 (5–12)		8 (6–12)		0 (0–3)
Obsessive compulsive disorder and related disorders
Yes	22 (16–26)	0.3	7 (5–12)	0.6	9 (6–11)	0.12	0 (0–3)	0.9
No	18 (15–24)		8 (6–11)		11 (7–12)		0 (0–3)
Personality disorders
Yes	16 (14–19)	0.4	5 (3–8)	0.3	7 (6–8)	0.078	3 (2–4)	0.3
No	20 (15–24)		8 (5–11)		10 (7–12)		0 (0–3)
Schizophrenia spectrum and psychotic disorders
Yes	16 (16–16)	0.5	0 (0–0)	0.10	4 (4–4)	0.14	1 (1–1)	0.8
No	20 (15–24)		8 (5–11)		10 (7–12)		0 (0–3)
Substance use disorder
Yes	20 (17–23)	0.7	12 (8–12)	0.02*	13 (10–16)	0.024*	0 (0–4)	0.9
No	20 (15–24)		7 (5–10)		9 (6–11)		0 (0–3)
Trauma and stress-related disorders
Yes	16 (15–24)	0.4	7 (6–10)	0.9	10 (4–11)	0.3	1 (0–2)	0.8
No	21 (16–24)		8 (5–12)		10 (7–13)		0 (0–3)

IQR = interquartile range

Associations among Contextual Factors and Parent Depression

The median depression score among the sample of parents was 9.5 (elevated), ranging from 4 to 20. The median depression score was higher in parents of male adolescents than female adolescents (11 vs. 8, p = .007). Median depression scores were also higher among parents whose adolescents were diagnosed with substance use disorders than parents whose adolescents were not diagnosed with substance use disorders (13 vs. 9, p = .024). Median depression scores were also higher among parents with adolescents diagnosed with bipolar and depressive disorders than parents whose adolescents were not diagnosed with bipolar and depressive disorders (11 vs. 8, p = .019). Median depression scores were lower in parents with adolescents diagnosed with disruptive, impulsive-control, and conduct disorders than in parents whose adolescents were not diagnosed with disruptive, impulsive-control, and conduct disorders (6 vs. 10, p = .025).

Associations among Contextual Factors and Parent PTSD

The median PTSD score among the sample of parents was 0 (low) with a range of 0 to 6. There was a significant association between marital status and PTSD. The median PTSD score was higher among unpartnered parents than partnered parents (0 vs. 5, p = .002).

Discussion

Overall, parents on average exhibited elevated depressive symptoms, moderate stress, mild-to-moderate anxiety, and subthreshold PTSD symptoms, which is consistent with the previous literature that suggests parents may struggle with their mental health (Baker et al., 2005, 2007; Dale et al., 2007; Griffith et al., 2009). While there are certainly differences among families, RT facilities, and programming across the US (Herbell & Ault, 2021), some parents experience significant adversity and challenging circumstances that increase susceptibility to mental health problems (Griffith et al., 2009). Despite the differences in subpopulations among the RT population, there is consistency in that parents’ stress is heightened when accessing intensive services like RT (Harder et al., 2018; Herbell et al., 2020). The RT paradigm is shifting away from a child-centric to a family-driven approach (Brown et al., 2010; Whittaker et al., 2016). In part, our findings support that prompt mental health screening and treatment for parents may be necessary because effective RT takes into account that the adolescent’s home and family environment are critical for the adolescent’s health (Geurts et al., 2012; Huefner et al., 2015; Robst et al., 2014).

Heightened Stress in Parents with Adolescents Currently Admitted

We compared stress levels between parents whose adolescents resided in RT at the time of the study to parents with adolescents living in places other than RT (e.g., home, inpatient facility). Results suggest that the median perceived stress score was higher in parents whose adolescents were currently living in an RT facility compared to parents whose adolescents were not currently living in an RT facility. A potential reason for this difference may be stress around discharge or an upcoming discharge date (Hess et al., 2012; Patel et al., 2019; Herbell & Breitenstein, 2020; Tahhan et al., 2010). Parents report that the transition period from RT to the community is highly stressful because parents take multiple steps to prepare for their adolescent to reenter the home, such as psychoeducation and arranging for other supports such as psychiatry appointments (Hess et al., 2012; Herbell & Breitenstein, 2020). Some parents have reported that as they prepare for their adolescent’s discharge, they feel the need to mimic the highly structured and secure RT environment in the home (Patel et al., 2019; Herbell & Breitenstein, 2020). Mimicking the RT environment at home is unsustainable and is an additional stressor (Patel et al., 2019; Herbell & Breitenstein, 2020). While discharge is a significant stressor for parents with adolescents in RT (Hess et al., 2012; Patel et al., 2019; Herbell & Breitenstein, 2020), in the present study, we did not ask parents for a projected discharge date and therefore did not examine the relationship between perceived stress and length of time until discharge. Future studies should examine the relationship between time to discharge date and parent stress to identify points for intervention.

PTSD Symptoms Were Elevated in Unpartnered Parents

We compared partnered (e.g., married) parents to unpartnered (e.g., divorced and single) parents on mental health measures. We found that median PTSD scores were higher among unpartnered parents compared to partnered parents. The median PTSD score for partnered parents was 0, indicating no symptoms of PTSD (Prins et al., 2016). The median PTSD score for unpartnered parents was 5, indicating probable PTSD. Perhaps partnered parents have greater social support, which may buffer the effects of stress and reduce the risk of PTSD (Simon et al., 2019; Sripada et al., 2015). An additional explanation may be that divorce or separation can be traumatic events that may increase the risk of PTSD (Chung & Hunt, 2014). Research supports that families with adolescents in RT report pervasive isolation and that their social support and relationships with others are strained (Herbell et al., 2020; Preyde et al., 2011a, 2011b). Future research should examine the role social support plays as a buffer against stress in this population.

Differences in Parent Anxiety and Depression by Adolescent Diagnoses

Parent anxiety and depression were higher in parents with adolescents diagnosed with bipolar and depressive disorders or adolescents diagnosed with substance use disorders compared to parents with adolescents who were not diagnosed with these disorders. Our findings are consistent with the literature suggesting a bidirectional association between parent mental health and adolescent mental health (Leijdesdorff et al., 2017). However, there are likely other environmental factors that indirectly contribute to the strength of this association. For example, adolescents whose parents have a mental illness are at risk for developing a mental illness themselves (Leijdesdorff et al., 2017) through behavioral mechanisms such as modeling, coping, monitoring, and self-disclosure (Van Loon et al., 2014). An additional consideration when contextualizing these findings is that our study was cross-sectional and while we collected data from parents about when they first started noticing symptoms in their adolescent (M = 10 years; IQR 5–13), we do not know the actual timing of mental health symptom development in parents nor adolescents. Future studies should assess mental health symptom presentation timing and examine behavioral and environmental mechanisms contributing to the relationship between parent and adolescent mental health. Finally, hospitalizing a child is a very distressing experience for both parents and children, which may have also influenced the relationships between parent and adolescent mental health (Doyle et al., 2021; Harder et al., 2018; Ward & Gwinner, 2014).

We also found that the median anxiety and depression scores were lower in parents with adolescents diagnosed with disruptive, impulsive-control, and conduct disorders than parents whose adolescents were not diagnosed with these disorders. However, this result should only be interpreted in the context of the sample. We used a univariable analysis and there may be confounding since none of the adolescents were without a diagnosis. Thus, we compared adolescents with disruptive, impulsive-control, and conduct disorders to adolescents with other mental health disorders. The latter group could have diagnoses instead like substance abuse or depression. This result would be more surprising if we compared adolescents with conduct disorder and adolescents without any behavioral disorder at all.

Implications for Practice

From a socioecological perspective, the adolescent is viewed as part of the larger, nested family system, where the actions of the adolescent influence the family and vice versa. For example, the adolescent’s disruptive behaviors can be a source of distress for the entire family unit and higher levels of parent stress and mental health symptoms are also associated with greater adolescent behavior problems. This bidirectional relationship is supported by research that suggests that it is critical to engage the broader family system in concert with the adolescent to increase the effectiveness of RT (De Boer et al., 2007; Harder & Knorth, 2014; Huefner et al., 2015).

While our research supports that there were differences in parent perceived stress depending on where the adolescent was living, it is critical to note that parents in both groups reported moderate stress. This finding has implications for practice as it implies that stress in this population is chronically elevated across the treatment trajectory from admission through discharge (Harder et al., 2018; Herbell et al., 2020b; Herbell & Breitenstein, 2020). This research highlights an opportunity for providers in RT to screen for parent mental health symptoms, including stress, and to intervene early with parents. The RT admission is frequently focused on the adolescent with parent mental health becoming a focus only if there is noticeable and significant impairment. The mental health of parents should be seen as a priority and standard of care in RT. As a standard of care, providers should screen parents for mental health symptoms and assess their coping strategies. At the very least, parents should be referred to mental health providers and connect them to mental health resources in their community. Further, given the bidirectional nature between parent and adolescent health, we would also advocate for evidence-based family therapy to be a standard of care. Previous research shows that family therapy is not consistently delivered in RT settings (Herbell & Ault, 2021). Intervening with families through family therapy is just one means of improving family function and communication to increase the likelihood of sustained treatment gains.

Limitations

Limitations in this study include the cross-sectional design, limiting our ability to make causal inferences or examine how parent mental health changes over time . Second, our focus was on parent mental health symptoms in this study. Subsequently, we did not ask parents if they had ever been diagnosed with a psychiatric disorder or mental health treatment. Information about mental health diagnoses and treatment would provide important information about service utilization and potentially managing the symptoms. Third, we recruited participants from social media and while we designed a data integrity protocol, we were still unable to verify participants’ identities or experiences with RT. Finally, univariable statistical analysis and small group sizes limit our ability to generalize these findings.

Conclusion

Overall, our findings suggest that contextual factors such as gender, race, ethnicity, and living in RT were associated with parent perceived stress. Parent perceived stress was highest among parents who were not Hispanic or Latinx, belonged to the “other race” group, or had adolescents who belonged to the “other race” group. Perceived stress was higher in parents with adolescents residing in RT at the time of the study than in parents with adolescents living elsewhere. Depression scores were higher in parents of male adolescents than female adolescents. Further, while PTSD scores tended to be lower in the sample, the median PTSD score was higher among unpartnered parents than partnered parents.

Interestingly, when we examined relationships between parent-reported adolescent psychiatric diagnoses and parent mental health, there were only significant associations among adolescent diagnoses and parent anxiety and depression. Parent anxiety and depression were higher in parents with adolescents diagnosed with bipolar and depressive disorders and parents with adolescents diagnosed with substance use disorders than parents with adolescents who were not diagnosed with these disorders. However, the median anxiety and depression scores were lower in parents with adolescents diagnosed with disruptive, impulsive-control, and conduct disorders than parents whose adolescents were not diagnosed with disruptive, impulsive-control, and conduct disorders. The findings provide an important description of the mental health characteristics of an underserved and vulnerable population of parents. The findings also highlight an opportunity for providers to screen, intervene, and provide support to the entire family across the treatment trajectory.

Acknowledgments

The study team would like to offer our sincerest thanks to the parents who participated in the study.

Disclosure Statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This research was supported by Sigma ThetaTau and Jonas Philanthropies .