Running head: INTEGRATIVE REVIEW 1

Integrative Review of the Literature

Morgan Tyner

Bon Secours Memorial College of Nursing

Dr. Turner

NUR 4122: Nursing Research

October 30, 2018

“I Pledge…”
INTEGRATIVE REVIEW 2

Abstract

Purpose: The purpose of this integrative review is to examine adolescents’ experiences

reintegrating back into school after a psychiatric hospitalization.

Background: Adolescents experience many different stressors during reintegration from a

psychiatric hospital back into school. This re-entry period is essential for a successful transition.

Unsuccessful transitions increase depression, self-harm, mental health crisis, and negative long-

term effects, such as homelessness and death.

PICOT Question: How do adolescents, who are released from a psychiatric hospital, perceive

their experiences during their reintegration?

Method: This integrative review was conducted by examining research compiled from searching

online databases. The inclusion criteria of the articles chosen, included only qualitative or

quantitative, peer-reviewed articles published in English that were related to the PICOT question

of the writer.

Results and Findings: Successful transitions are associated with higher levels of satisfaction,

higher graduation rates, depression reduction and lower levels of self-harm. Appropriate levels of

support and coping skills are associated with a positive experience during re-entry into school.

Limitations: The most significant limitation is the author’s inexperience in conducting an

integrative review. Other limitations include the small number of articles reviewed and the

inclusion criteria of this integrative review.

Implications and Recommendations: The implications of this integrative review suggest that

adolescents should receive support and have help developing and utilizing coping skills to

increase satisfaction. Recommendations for future research should include quantitative research

to establish correlations between support and coping skills and the reintegration period.
INTEGRATIVE REVIEW 3

Integrative Review of the Literature

The purpose of this integrative review is to examine adolescents’ experiences

reintegrating back into school after a psychiatric hospitalization. According to Clemens, Welfare

and Williams (2011), a large portion of reintegration studies focus on adolescents who have been

released from a hospital due to medical illness. Twenty percent of youth experience a mental

health issue and 7% of all adolescent hospitalizations are due to mental illness (Clemens,

Welfare, & Williams, 2011; Preyde, Parekh, & Heintzman, J., 2018) However, little research has

been conducted on school re-entry after a psychiatric illness (Clemens et al., 2011; Moses, 2014;

Moses, 2015; Preyde et al., 2018; White, LaFleur, Houle, Hyry-Dermith, & Blake, 2017). The

studies discussed in this paper focus on the factors that influence the transition from a psychiatric

hospitalization back into school (Clemens et al., 2011; Moses, 2014; Moses, 2015; Preyde et al.,

2018; White et al., 2017).

Post-discharge from a mental health facility is a very stressful and vulnerable time for an

adolescent. Adolescents experience a myriad of stressors upon discharge, such as academic

demands, social expectations, follow-up treatment, and adjusting to home life (Clemens et al.,

2011; Moses, 2014; Moses, 2015; Preyde et al., 2018; White et al., 2017). It is imperative that

factors related to transitioning are understood because adolescents with mental illness have an

increased likelihood of poor health outcomes, such as homelessness and death (Moses, 2014;

Preyde et al., 2018; White et al., 2017). The aim of this review is to examine and discuss

published literature related to the writers PICOT question: How do adolescents, who are released

from a psychiatric hospital, perceive their experiences during their reintegration?

Design and Methods

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The research design of this paper is an integrative review. Five, peer-reviewed research

articles will be discussed and reviewed. The search for the selected articles was conducted by

utilizing online research databases through the Bon Secours eLibrary resource, MyAthens. The

search engines utilized for the purpose of this paper were: Academic Search Complete, PubMed,

and EBSCOHOST, specifically CINAHL Complete and Nursing Reference Center. The amount

of search terms and their arrangements explored was extensive, but for the sake of this review

only important and result yielding search terms will be mentioned. The search terms used were:

adolescent(s), psychiatric hospitalization, reintegration, school reentry, stigma, self-concept, and

coping skills. The searches conducted yielded only 17 articles, due to the lack of associated

research.

Due to the lack of studies on this subject, it was deemed acceptable to alter inclusion

criteria to include research conducted from 2011-2018. The articles chosen had to meet inclusion

criterium or were not deemed acceptable sources. The inclusion criteria included only qualitative

or quantitative, peer-reviewed articles published in English that were related to the PICOT

question of the writer, “How do adolescents, who are released from a psychiatric hospital,

perceive their experiences during their reintegration?” It was also necessary to only include

research by qualified authors (i.e. authors with terminal degrees in the associated research). After

ensuring that the research articles met the inclusion criteria, a final number of five qualitative

research studies were chosen for this paper.

Findings and Results

Findings and results among all five of the reviewed articles identify the necessity of

structured support during school reentry after a psychiatric hospitalization (Clemens et al., 2011;

Moses, 2014; Moses, 2015; Preyde et al., 2018; White et al., 2017). A summary of the five
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research articles is located at the end of this paper (see Appendix – Article Evaluations). The

following is a brief summary of each articles’ findings and results.

A quasi-experimental research study, conducted by White, LaFleur, Houle, Hyry-

Dermith and Blake (2017), the authors sought to present data supporting a school-based

transition program, The Bridge for Resilient Youth in Transition, for adolescents reentering

school after a psychiatric hospitalization. Researchers collected data from eight participating

schools in Maryland over three academic years. Out of 590 transition program participants, a

final sample of 189 program participants were chosen for data collection and measures (White et

al., 2017). The mixed methods design allowed the authors to study both qualitative and

quantitative data on students’ experiences and progress while enrolled in the school-based

transition program (White et al., 2017).

Trained clinicians used the Child & Adolescent Functional Assessment Scale (CAFAS),

at intake into the program and after the adolescent had spent eight to twelve weeks in the

transition program (White et al., 2017). The CAFAS is a reliable tool in assessing and measuring

adolescents’ difficulty functioning in daily life by having interitem reliability as well as inter-

rater reliability through the measurement of subscales related to day-to-day functioning (White et

al., 2017). The researchers examined the eight subscale scores of CAFAS at intake and follow-

up, which included: school functioning, home behavior community behavior, behavior toward

others, moods and emotions, self-harmful behavior, substance use, and rational thinking.

SPSS Version 24 analyzed the gathered data and statistical comparisons of samples were

analyzed with paired t-tests. The data collected from the CAFAS scores indicated that

adolescents entering the program, had much poorer CAFAS scores than at the eight to twelve-

week follow-up (White et al., 2017). Functioning improved in five out of eight of the subscales,
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according to White et al. (2017). The most statistically significant improvements were in the

following: self-harm scale, moods and emotions scale, and school functioning scale (White et al.,

2017).

Similar results were presented in the qualitative research article published by Preyde,

Parekh, & Heintzman, J. (2018). The authors claimed that 38 of the 62 adolescents from Ontario,

Canada, who responded to a follow-up study, stated that support from professionals, school

personnel, friends and family helped their transition (Preyde et al., 2018). The theoretical

framework is not mentioned in the paper; however, it is stated that this study was purely

exploratory to examine adolescent’s experiences after discharge from a mental health facility

(Preyde et al., 2018). Researchers conducted two open-ended surveys, over the phone or online,

with consenting adolescents. The first survey was conducted at discharge and the second was

conducted two weeks later, and both included two survey instruments to measure participants

experiences (Preyde et al., 2018).

The first instrument utilized was a valid and reliable survey called Strengths and

Difficulties self-report scale (SDQ), which included five subscales: emotional problems,

hyperactivity, conduct problems, peer problems, and prosocial behavior (Preyde et al., 2018).

The second survey instrument measured school engagement by 5-point response option of the

modified subscale, the Child report version of The MacArthur Health and Behavior

Questionnaire (HBQ-C) (Preyde et al., 2018). HBQ-C measured the difficulties adolescents

experienced coming back to school, such as, academic difficulties and school avoidance (Preyde

et al., 2018). A third survey instrument, Global Clinical Impression scale, was obtained from the

most responsible psychiatrist (MRP) with scores ranging from normal to extremely ill.
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Thematic content analysis was used to examine the data gathered, then two researchers

independently categorized and filed the data. After consensus was reached between researchers,

Bonferroni correction was used to interpret the results. Almost 52 % of adolescents reported a

positive-neutral experience reintegrating and 48.3% reported a negative experience reintegrating

(Preyde et al., 2018). Adolescents who reported having a highly negative experience

transitioning, had significantly less improvement reported by the MRP (Preyde et al., 2018).

Similar to the study mentioned above, Clemens, Welfare, and Williams (2011)

consensual qualitative research article inductively examined the phenomenon of reintegration of

adolescents by analyzing the experiences of mental health professionals. The 14 randomly

selected mental health professionals from represented clients who received care in four separate

psychiatric facilities, four separate school districts and in three different states in the Midwestern

United States (Clemens et al., 2011). Data collection techniques of this study included an hour-

long interview with eight open-ended questions. Data was then gathered and sent to a third-party

company which transcribed the interviews (Clemens et al., 2011). The data gathered was

assessed by the initial research team to be sorted into five categories to be coded (Clemens et al.,

2011). These categories were then coded in NVivo to ensure that data was properly assessed.

After this coding process by the research team, the sorted data was sent to another independent

auditor who then confirmed the integrity of the data analysis. Researchers finally concluded that

five main areas of related factors affect reentry into school after psychiatric hospitalization

(Clemens et al., 2011).

The five areas were established during the data analysis portion of the study and include:

school-based factors, student factors, familial factors, mental health care factors, and systemic

factors (Clemens et al., 2011). These factors represent the most important aspects affecting
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reintegration back into school, whether positively or negatively. The authors stated the data

indicates a great need for communication between all members of the healthcare team, school

faculty, families and patient (Clemens et al., 2011). The researchers also stated communication

and planning are essential to making the transition process more successful (Clemens et al.,

2011).

A qualitative, mixed methods study conducted by Moses (2014), aimed to examine social

and clinical factors that influence and predict self-reported stigma by adolescents recently

released from a mental health facility. Moses (2014) claims this phenomenon is important to

study because it could predict negative experiences such as, devaluation and social rejection after

a hospitalization. Self-reported stigma, or enacted stigma, is defined as the negative, internalizing

perceptions that adolescents experience about themselves after a psychiatric hospitalization

(Moses, 2014).

Eighty, adolescent participants from a mid-sized city in Wisconsin, voluntarily consented

to two home interviews following a hospitalization in a non-profit psychiatric hospital (Moses,

2014). The first interview was conducted seven days after discharge and the second interview

was conducted six months later. The interviews included open-ended questions pertaining to:

social support, quality of relationships with friends, number of friends, peer group identification,

clinical symptoms, and school functioning (Moses, 2014). Analyses were conducted using SPSS,

and a multivariate OLS regression analysis with a two-tailed test was utilized to examine

participants responses (Moses, 2014). At the six-month follow-up, 40% of participants reported

that people hurt their feelings by using the point that they were in treatment for a mental health

issue, compared to only 25% at the first interview (Moses, 2014). The data also concluded that

participants who affiliated with the “popular crowd” experienced more stigma and social
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isolation from their peers (Moses, 2014). However, the bigger the social support system of peers

and number of friends increased the likelihood of stigma by peers (Moses, 2014).

In another qualitative, mixed methods research article by Moses (2015), results

concluded that coping strategies and self-stigma was measured to affect adolescents discharged

from a non-profit psychiatric facility in a Midwestern city in the United States. The aim of the

study was to examine how anticipated coping strategies used by transitioning adolescents and to

examine if the coping strategies predicted self-stigma after six months (Moses, 20150. Two,

open-ended, face-to-face interviews were conducted at the homes of the consenting participant at

two different time tables. The first interview was conducted at seven days post-discharge and the

second was six months after. The adolescents were given a Responses to Stress Questionnaire

(RSQ) with 32 items that explored coping strategies used (Moses, 2015).

SPSS version 20 was utilized by the researcher to provide descriptive statistics for stigma

and coping data (Moses, 2015). Ordinary least squares regression was utilized to predict if initial

coping strategies predicted stigma at the six-month interview (Moses, 2015). Multivariate

general lineal modeling and structural equation modeling analyzed and tested all of the data at

each time period (Moses, 2015). The data results presented by Moses (2015), reported that the

most common coping strategy by was primary control engagement coping (PCEC). PCEC is a

conscious effort to approach or control stressful situations by problem solving, seeking help, and

by expressing oneself and again at six months later (Moses, 2015). However, the results

presented evidence that secondary control engagement coping (SCEC) was important to modify

self-stigma experienced by the student (Moses, 2015). SCEC is the practice of the individual

gaining control over their thoughts and their feelings by acknowledging their strengths and
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comparing it to their situation or perceived stigma (Moses, 2015). The use of SCEC increases the

level of positive thinking, cognitive restructuring, and acceptance (Moses, 2015).

Discussion and Implications

The articles selected for this review indicate a need for adolescents to be supported

during reintegration from a psychiatric hospitalization back to school to increase the probability

of a successful transition (Clemens et al., 2011; Moses, 2014; Moses, 2015; Preyde et al., 2018;

White et al., 2017). White et al. (2017), stated that adolescents who do not receive sufficient

support after discharge have a higher chance of readmission compared to adults. In contrast,

adolescents who received support throughout the transition experienced a better sense of well-

being and had lower rates of readmission (White et al., 2017). Lower hospitalization

readmissions and higher graduation rates were noted in the population of students who did

receive psychosocial support, as well as counseling for coping strategies (Moses, 2014; Moses,

2015; White et al., 2017). These discussions and implications provided below relate to and

support the authors PICOT question.

Support

There was consensus among all five articles that support plays a major role in influencing

an adolescents’ experience transitioning back into school (Clemens et al., 2011; Moses, 2014;

Moses, 2015; Preyde et al., 2018; White et al., 2017). Clemens et al. (2011) claimed that support

from healthcare workers, school staff, and family members play a big role in easing the process

of re-entry. A common finding identified in each of the research articles was that adolescents

who had less support from family, friends, school, and medical staff were more likely to report a

negative experience transitioning back into school (Clemens et al., 2011; Moses, 2014; Moses,

2015; Preyde et al., 2018; White et al., 2017). Some impacts of having a negative experience
INTEGRATIVE REVIEW 11

during school re-entry included: self-harming, academic difficulty, withdrawal, substance abuse

and relapse into a mental health crisis (Clemens et al., 2011; Preyde et al., 2018; White et al.,

2017).

Lack of support from teachers resulted in many students becoming overwhelmed by the

academic demands (Clemens et al., 2011; Preyde et al., 2018). According to White et al. (2017),

students who do not receive adequate support were more likely to reenter a psychiatric facility

due to another mental health crisis. One research article suggest that an individual should take on

the role of a leader in the transition phase of reentry (Clemens et al., 2011). The researchers

stated that a “reentry coordinator” should act as a liaison for the student between the healthcare

system, the school system, and the family to ensure proper communication and interventions

(Clemens et al., 2011).

Coping Skills

Preyde et al. (2018) claimed that coping skills and symptom management should be

evaluated and individualized into a plan of care for the adolescent prior to discharge. Evaluating

the coping skills before discharge could help identify adolescents at-risk for a negative transition,

thus reducing the negative impacts (Preyde et al., 2018). Moses (2015) also discussed the

importance of identifying “anticipated coping strategies” as they are an indicator of the stigma

that adolescents perceive during transition. Perceived stigma has a negative effect on

transitioning adolescents and can cause profound, long-lasting negative experiences after

hospitalization such as shame, withdrawal, and self-directed negativity (Moses, 2015).

Moses (2014) stated that there is substantial evidence from past research articles that peer

rejection in adolescence has negative long-term effects. If a student lacks the appropriate coping

skills to overcome peer rejection, there is an increased likelihood of depression, mental health
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crisis, and self-harm (Moses, 2014; Preyde et al., 2018). In another study by Moses (2015), the

results suggested that SCEC was significant in lowering depression and increasing self-esteem.

The use of SCEC helps the student overcome perceived stigma and increases levels of

satisfaction with reintegration (Moses, 2015). Future research needs to be done to further these

findings and results so that they can help guide future practice.

Limitations

In this integrative review, there were many limitations noted by the writer. The writers

lack of experience and lack of knowledge about integrative reviews is a limitation factor. The

writer is not a researcher and does not hold a nursing degree. It is necessary to say that this

review is neither reliable or an in-depth review of the topic discussed.

Another limitation is the inclusion criteria used to choose the articles reviewed in this

paper. This is by no means an exhaustive review on the literature. The small amount of studies

reviewed in this paper was not substantial and cannot provide an adequate, nor comprehensive

review of the subject matter. No substantial conclusions can be made, only suggestions for future

studies made by the author.

The author of this integrative review found several limitations in the five articles

presented, including: limited sample sizes, lack of associated research, and limited interview

techniques. The articles themselves have several limitations that were not discussed in this

integrative review due to limitations on page count. One study concluded that there needs to be

quantitative research studies conducted to investigate the factors relevant to a successful

transition for adolescents (Clemens et al., 2011)

Conclusions
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The evidence compiled for this integrative review supports the idea that adolescents who

receive support during school reintegration have better outcomes than those who lack support

(Clemens et al., 2011; Moses, 2014; Moses, 2015; Preyde et al., 2018; White et al., 2017).

Support from staff, friends, family and health professionals is imperative for a successful

transition from a psychiatric hospital back into school. Also, positive outcomes reported by

adolescents are associated with coping skills the student utilizes to overcome the stressors of

reintegration (Moses, 2014; Moses, 2015; Preyde et al., 2018). Researchers should consider

conducting quantitative studies on the use of support and coping skills for a student reintegrating

back into school. In relation to the PICOT question being addressed, the literature suggests that

adolescents receiving support throughout transition have a better experience than those who do

not receive support.

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References

Clemens, E. V., Welfare, L. E., & Williams, A. M. (2011). Elements of successful school

reentry after psychiatric hospitalization. Preventing School Failure, 55(4), 202–213.

doi: 10.1080/1045988X.2010.532521

Moses, T. (2014). Determinants of mental illness stigma for adolescents discharged from

psychiatric hospitalization. Social Science & Medicine, 109, 26-34.

doi.org/10.1016/j.socscimed.2013.12.032

Moses, T. (2015). Coping strategies and self-stigma among adolescents discharged from

psychiatric hospitalization: A 6-month follow-up study. International Journal of Social

Psychology, 61(20), 188-197. doi: 10.1177/0020764014540146

Preyde, M., Parekh, S. & Heintzman, J. (2018). Youths’ experiences of school re-integration

following psychiatric hospitalization. Journal of The Canadian Academy of Child and

Adolescent Psychiatry, 27(1). 22-32. Retrieved from

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5777688/

White, H., LaFleur, J., Houle, K., Hyry-Dermith, P., & Blake, S. M. (2017). Evaluation of a

school-based transition program designed to facilitate reentry following a mental health

crisis or psychiatric hospitalization. Psychology in the Schools, 54, 868-882.

doi:10.1002/pits.22036
INTEGRATIVE REVIEW 15

Appendix

Article Evaluations

Table 1

APA Citation for Clemens, E. V., Welfare, L. E., & Williams, A. M. (2011). Elements of
Article
successful school

reentry after psychiatric hospitalization. Preventing School

Failure, 55(4), 202–213.

doi: 10.1080/1045988X.2010.532521

Author(s) - Clemens: Ph.D. in counseling and counselor education

Qualifications Welfare: Ph.D, associate professor at Virginia Tech
Williams: Ph.D, Psychologist

Background/Problem The problem statement presented by the authors was to identify the
Statement “Assets” (benefits) and “Barriers” (obstacles) that students face when
reentering school after a psychiatric hospitalization.

Conceptual/theoretical A framework for the study was not clearly stated in the article due to
Framework lack of research into the reentry of psychiatric patients into school.
 consensual qualitative research (CQR).
Design/Method CQR approach to provide structure and analysis guidelines for the data
If appropriate, gathered.
Philosophical
Underpinnings

Sample/ Fourteen mental health professionals:

Setting/Ethical Four professionals working in inpatient settings
Considerations Outpatient professionals in private practice and community agencies
Six professionals working in the school setting, school counselors
Ethics is not mentioned. The researchers claimed participants identities
were protected by using pseudonyms and sending the interviews to an
independent transcription company. However, it is unclear if the
participants in the study were protected from harm and if
confidentiality was guaranteed.

Major Variables Inpatient clinicians

Studied (and their Outpatient clinicians
definition), if School mental health professionals
appropriate
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Measurement
Tool/Data Collection The appropriate sampling method used was a mixture of random
Method sampling methods modeled by CQR.

Data Analysis  hour-long interview with eight open-ended questions.

 third-party company transcribed interviews.
 NVivo
 independent auditor who then confirmed the data analysis

Findings/Discussion Five main areas of related factors affect reentry into school after
psychiatric hospitalization: school-based factors, student factors,
familial factors, mental health care factors, and systemic factors.
These factors represent the most important aspects affecting
reintegration back into school, whether positively or negatively.

Appraisal/Worth to The study cannot be determined as useful in nursing practice due to the
practice lack of trustworthiness and associated research.

Table 2

APA Citation for White, H., LaFleur, J., Houle, K., Hyry-Dermith, P., and Blake,
Article
S. M. (2017). Evaluation of a

school-based transition program designed to facilitate

reentry following a mental health crisis

or psychiatric hospitalization. Psychology in the Schools,

54, 868-882. doi:10.1002/pits.22036

Author(s) - Henry White: Psychiatrist and Clinical Director of Brookline

Qualifications Community Health Center
Jennifer LaFleur: Research Analyst, Current Doctoral Student
and holds an M. Ed from Harvard University
Katherine Houle: L.I.C.S.W (Licensed Independent Clinical
Social Worker), Associate Director of Brookline Community
Health Center
Paul Hyry-Dermith: Ed.D with over 20 years in education and
current Director of Brookline Community Health Center
INTEGRATIVE REVIEW 17

Susan M. Blake: Ph.D, Associate Research Professor at GWU,

years of experience in clinical research, public and community
health
Background/Problem The paper lacks a clear purpose statement but it does state: “This
Statement paper presents results of a study examining a school-based
support program model designed to provide short-term academic,
social, and emotional support to help students successfully
reacclimatize to school after an extended absence.”
“The number of adolescents who experience a psychiatric
hospitalization increased by nearly 300% over the past 20 years.”
“Returning students face difficulties in functioning, risk of
relapse, and are vulnerable to academic failure and social
isolation.”
Conceptual/theoretical Response to Intervention framework (more recently named
Framework Multi-Tiered systems of Support or MTSS)
“integrates assessment and intervention within a multilevel
prevention and intervention system to maximize student
achievement and to reduce behavioral problems.”
Design/Method “One group, pretest-posttest pre-experimental research design”
If appropriate,
Philosophical
Underpinnings

Sample/ “Eight high schools that operated transition programs based on

Setting/Ethical the model agreed to participate in the evaluation and collected
Considerations data during 2013-2014 and 2014-2015.”
“HIPPA and FERPA compliant database”
Final sample was 189 students with a “primary mental health
diagnosis on admission into the transition program”
Major Variables  Gender, Race/Ethnicity, Other Characteristics: Special
Studied (and their education, Free or Reduced-Price Lunch
definition), if  Demographic, academic, clinical variables, program
appropriate utilization, school attendance, and school
enrollment/graduation data
 Diagnosis at admission, Clinical status prior to admission
 CAFAS Subscale Scores
Measurement  Child and Adolescent Functional Assessment Scale
Tool/Data Collection (CAFAS)
Method  Staff members collected and entered student academic,
clinical, and participation data into the HIPPA and
FERPA compliant database
Data Analysis  SPSS Version 24
 Paired t-tests
INTEGRATIVE REVIEW 18

Findings/Discussion “Data collected by program clinicians indicated that transition

program participants were having a great deal of difficulty in
their day-to-day functioning when they first returned to school.”
“Statistically and clinically significant improvements were seen
in program staff members’ ratings of students’ overall
functioning, most significantly in relation to moods/emotions,
self-harmful behaviors, and school functioning between intake
and follow-up 8-12 weeks later.”

Appraisal/Worth to “Outcomes are descriptive in nature”

practice “The results confirm the extraordinary level of need among
students with a primary mental health diagnosis and suggest that
participation was associated with an improvement in students’
day-to-day functioning and school persistence.”
“The paper considers implications for school-based mental health
practice and next steps in related research”

Table 3

APA Citation for Preyde, M., Parekh, S. & Heintzman, J. (2018). Youths’
Article experiences of school re-integration following psychiatric
hospitalization. Journal of The Canadian Academy of Child
and Adolescent Psychiatry, 27 (1). 22-32. Retrieved from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5777688/
Author(s) - Preyde: PhD in social work, Professor of Social Work
Qualifications Parekh: MD, Psychiatrist
Heintzman: MD, Psychiatrist, Chief of Psychiatry at Grand
River Hospital, Ontario
Background/Problem “The purpose of this study was to explore the youths’
Statement perceptions of school reintegration following psychiatric
hospitalization, and to explore clinical features (i.e.,
selfreported mental health problems and psychiatrist
reported acuity, length of stay (LOS), and improvement)
and school variables (i.e., school engagement, academic
difficulty and
school refusal) associated with negative school re-entry
experiences.”

Conceptual/theoretical The theoretical framework is not mentioned in the paper.

Framework However, it is stated that this study was purely exploratory
to examine adolescent’s experiences after discharge from
a mental health facility.
Design/Method  Qualitative study
 Open-ended surveys
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If appropriate,  Exploratory
Philosophical  Searched keywords: Adolescent, Reintegration,
Underpinnings Psychiatric hospitalization, stigma, self-concept

Sample/  Out of 161 adolescents originally surveyed, only 121

Setting/Ethical actually consented and only 60 responded to the
Considerations survey.
 One psychiatric facility serving multiple populations
of cities and rural areas in Canada
 Institutional clearance was provided by the
Research Ethics Boards of Grand River Hospital and
the University of Guelph.
 The researchers gained informed consent from
caregivers and then informed consent from each
participant.
Major Variables  If patients had previous hospitalizations
Studied (and their  Transitional Support Services offered by each
definition), if community. The researchers define TSS as
appropriate “multidisciplinary team treatment approach that
includes Child and adolescent psychiatrists, mental
health nurses, social workers, a child youth worker
and a occupational therapist.
 School engagement, school performance, academic
difficulty,
Measurement  Initial survey given inpatient
Tool/Data Collection  Follow up survey after discharge over phone or
Method through email and an online survey
 Open-ended questions
 Four items were on a rating scale
 Mental health problems were measured with the
Strengths and Difficulties self-report scale
 School engagement was measured with the School
Engagement Scale
 Academic difficulties and school avoidance were
measured with modified subscales of the Child
report version of The MacArthur Health and
Behaviour Questionnaire
 Clinical features were obtained from the most
responsible psychiatrist (MRP) who provided clinical
information based on the Global Clinical Impression
scale

Data Analysis
 Thematic content analysis was used to
INTEGRATIVE REVIEW 20

 Two trained research assistants analyzed the data

independently, with agreement on all but one case,
and consensus was readily reached with discussion.
 Bonferroni correction was used to interpret the
results of the total SDQ and emotional subscale with
two separate t-tests

Findings/Discussion  Youth who reported negative reintegration

experiences had more emotional problems and had
less improvement while hospitalized
 Findings could provide useful to identify at-risk youth
who are more likely to have poor outcomes

Appraisal/Worth to  More data and more studies are needed to positively

practice identify the value of worth for practice.

Table 4

APA Citation for Moses, T. (2014). Determinants of mental illness stigma for
Article adolescents discharged from psychiatric hospitalization.
Social Science & Medicine, 109, 26-34.
doi.org/10.1016/j.socscimed.2013.12.032
Author(s) - Tally Moses: PhD, Master of Social Work. Associate
Qualifications Professor
Background/Problem Very little research exists on the stigma that adolescents
Statement face when returning to their peers and life after a
psychiatric hospitalization. The purpose of this study is to
examine the social and clinical factors that increase the
stigma associated with mental illness.

Conceptual/theoretical  Social Identity Theory

Framework

Design/Method  All interviews followed a semi-structured interview

If appropriate, protocol that included open-ended questions and
Philosophical quantitative rating scales.
Underpinnings  Searched keywords: Adolescent, Reintegration,
Psychiatric hospitalization, stigma, discharge,
depression, self-concept

Sample/  First interviews had 102 participants but in the
Setting/Ethical second interview the sample was 80 adolescents,
Considerations aged 13-18
INTEGRATIVE REVIEW 21

 Patients were from a non-profit hospital in a mid-

sized city in Wisconsin, U.S.A.
 Interviewed at their home seven days after their first
hospitalization. A follow-up interview was done six
months later.
 Researchers gained informed consent from parents
and legal guardians and then gained informed
consent from the patients themselves
 Patients with extensive developmental delays,
mentally incapacitated or “floridly” psychotic were
excluded from the study
 “All participants and parents guardians also signed
HPPA forms allowing the study team to access
certain information from their online hospital records.
Interviews lasted approximately 2 hours and
participants were compensated $30 and $35
respectively for the first and second interviews.”
 “This study received ethics approval from the
University of Wisconsin and Meriter Hospital IRB
committees.”
Major Variables  Variables at first interview: Social context, Quality of
Studied (and their relationship with friends, number of friends, peer
definition), if group identification, number of friends with mental
appropriate health problems, clinical symptoms, school
functioning, School disciplinary problems, special
learning needs
 Variables at second interview: Enacted social
stigma, Perceived public stigma
Measurement  “All analyses were conducted using SPSS.”
Tool/Data Collection  “Bivariate associations were conducted between
Method enacted stigma (Time 2) and each of the predictor
variables (at Time 1 and Time 2) using student’s t-
test for continuous variables and chi-square for
categorical variables.
 “A multivariate OLS regression analyses with a two-
tailed test was used to explore the most robust
correlates of adolescents’ enacted stigma at 6-
months, including variables significant as bivariates
at p < .05.”
 “OLS regression analysis was used to identify which
of the factors held up in multivariate analysis”

Data Analysis  Limitations of the study include short duration of time

between initial interview and follow-up and the small
sample size.
INTEGRATIVE REVIEW 22

 The majority of the sample size was of one

demographic. Patients were largely white and
middle class.

Findings/Discussion  “Six months following their discharge from

psychiatric hospitalization, 70% of adolescents
reported experiencing one or more aspects of
enacted mental illness stigma. Most of the stigma
reported was not outright social rejection, but rather
general devaluation, disrespect, emotional insult,
and being under-estimated by others.”
 The findings suggest that adolescents with a higher
social standing (i.e. popular, many friends) may face
more stigma after being discharged from a
psychiatric hospital.
 These findings may be useful in identifying
adolescents at-risk for bullying or discrimination after
discharge.
Appraisal/Worth to  The researcher states there should be more
practice research done on stigma and social relationships
and how the stigma manifests itself.
 “To develop more sensitive assessment tools and
productive prevention and intervention efforts,
additional research is necessary to further deepen
our understanding of the individual-level and setting-
level attributes that protect against or increase the
risk for mental illness stigmatization.”

Table 5

APA Citation for Moses, T. (2014). Determinants of mental illness stigma for
Article adolescents discharged from psychiatric hospitalization.
Social Science & Medicine, 109, 26-34.
doi.org/10.1016/j.socscimed.2013.12.032
Author(s) - Tally Moses: PhD, Master of Social Work. Associate
Qualifications Professor
Background/Problem Very little research exists on the stigma that adolescents
Statement face when returning to their peers and life after a
psychiatric hospitalization. The purpose of this study is to
examine the social and clinical factors that increase the
stigma associated with mental illness.

Conceptual/theoretical  Social Identity Theory

Framework
INTEGRATIVE REVIEW 23

Design/Method  All interviews followed a semi-structured interview

If appropriate, protocol that included open-ended questions and
Philosophical quantitative rating scales.
Underpinnings  Searched keywords: Adolescent, Reintegration,
Psychiatric hospitalization, stigma, discharge,
depression, self-concept

Sample/  First interviews had 102 participants but in the
Setting/Ethical second interview the sample was 80 adolescents,
Considerations aged 13-18
 Patients were from a non-profit hospital in a mid-
sized city in Wisconsin, U.S.A.
 Interviewed at their home seven days after their first
hospitalization. A follow-up interview was done six
months later.
 Researchers gained informed consent from parents
and legal guardians and then gained informed
consent from the patients themselves
 Patients with extensive developmental delays,
mentally incapacitated or “floridly” psychotic were
excluded from the study
 “All participants and parents guardians also signed
HPPA forms allowing the study team to access
certain information from their online hospital records.
Interviews lasted approximately 2 hours and
participants were compensated $30 and $35
respectively for the first and second interviews.”
 “This study received ethics approval from the
University of Wisconsin and Meriter Hospital IRB
committees.”
Major Variables  Variables at first interview: Social context, Quality of
Studied (and their relationship with friends, number of friends, peer
definition), if group identification, number of friends with mental
appropriate health problems, clinical symptoms, school
functioning, School disciplinary problems, special
learning needs
 Variables at second interview: Enacted social
stigma, Perceived public stigma
Measurement  “All analyses were conducted using SPSS.”
Tool/Data Collection  “Bivariate associations were conducted between
Method enacted stigma (Time 2) and each of the predictor
variables (at Time 1 and Time 2) using student’s t-
test for continuous variables and chi-square for
categorical variables.
INTEGRATIVE REVIEW 24

 “A multivariate OLS regression analyses with a two-

tailed test was used to explore the most robust
correlates of adolescents’ enacted stigma at 6-
months, including variables significant as bivariates
at p < .05.”
 “OLS regression analysis was used to identify which
of the factors held up in multivariate analysis”

Data Analysis  Limitations of the study include short duration of time

between initial interview and follow-up and the small
sample size.
 The majority of the sample size was of one
demographic. Patients were largely white and
middle class.

Findings/Discussion  “Six months following their discharge from

psychiatric hospitalization, 70% of adolescents
reported experiencing one or more aspects of
enacted mental illness stigma. Most of the stigma
reported was not outright social rejection, but rather
general devaluation, disrespect, emotional insult,
and being under-estimated by others.”
 The findings suggest that adolescents with a higher
social standing (i.e. popular, many friends) may face
more stigma after being discharged from a
psychiatric hospital.
 These findings may be useful in identifying
adolescents at-risk for bullying or discrimination after
discharge.
Appraisal/Worth to  The researcher states there should be more
practice research done on stigma and social relationships
and how the stigma manifests itself.
 “To develop more sensitive assessment tools and
productive prevention and intervention efforts,
additional research is necessary to further deepen
our understanding of the individual-level and setting-
level attributes that protect against or increase the
risk for mental illness stigmatization.”