Domain 8 - Engagement and motivation (Contextual Domain)

Overview

This domain considers the adolescent or their parent/caregiver’s awareness of the mental health issue and their motivation to engage in or accept assistance.

Many adolescents do not have the agency or resources required to seek and access services and support independently. Therefore, the engagement and motivation of the parent/caregiver is the primary determinant of access and uptake, and the parent/caregiver sub-scale is used. Whilst the parent/caregiver sub-scale rates the engagement and motivation of the parent/caregivers, the adolescent should be included in discussions, using language they understand, and supported to express their choices, preferences, fears, and goals about referral next steps.

The parent/caregiver sub-scale is used when the adolescent cannot exercise decision-making control of their healthcare decisions. The parent/caregiver sub-scale considers:

• Ability and capacity to support the adolescent to manage the condition.

• The parent/caregiver’s motivation to assist the adolescent to access necessary support (critical if considering self-management options).

Conversely, where the adolescent can exercise decision-making control of their healthcare decisions, the adolescent’s engagement and motivation take precedence (adolescent sub-scale). The adolescent sub-scale considers:

• The adolescent’s motivation to participate in the recommended services and support.

PRACTICE POINT - Checking in when engagement or motivation is low

A follow-up check-in helps determine if the recommended information, resources, or services are being utilised and perceived as helpful. Proactively “checking in” or encouraging the adolescent and parent/caregiver to “check back” is essential when engagement or motivation is low. A plan for check-in should be made at the point of referral and documented.

The check-in should explore the following questions:

1. Is the adolescent engaging with the recommended information, resources, and services? If the adolescent is not engaging, it is essential to re-examine motivation and explore reasons for the lack of engagement.

2. Does the adolescent think that the recommended information, resources, and services are/were helpful?

3. Is there evidence of deterioration or changing risk of suicide or harm to self or others?

4. Is the adolescent experiencing new or worsening social and environmental stressors?

5. Discuss and document the next steps in collaboration with the adolescent. The next steps might include:

• Continue existing service arrangements

• Build in additional supports

• Initiate a referral to a different level of care

Practice point – informed consent

Clinicians have legal and ethical obligations to obtain informed consent before performing any healthcare intervention. To give informed consent, a person (or the person making decisions for them if they cannot make decisions for themselves) should be sufficiently informed of the risks and benefits of any treatment (including, where relevant, the risk associated with no treatment).

The process of gaining consent for the treatment of children and adolescents (under the age of 18) differs significantly from that of adults and is more complex and varied. In some instances, consent must be given by the relevant parent or guardian, whereas in others, it may be possible for a person under 18 who is a ‘mature minor’ to give consent. A mature minor is a child or adolescent assessed as having the capacity to make specific decisions based on various factors, including the nature of the treatment, age, maturity, medical/social history, degree of independence, understanding, and intelligence. If a child or adolescent is a mature minor, consent for treatment is not required from a parent or guardian.

Depending on the circumstances, involvement of both the parent/guardian and a child/adolescent in providing consent for assessment, referral and intervention can be preferable.

Where, on balance, the risk of engagement of the parent will lead to a potential negative impact on the child or adolescent, consideration may need to be given to the involvement of an alternative guardian if the child or adolescent is not a mature minor and cannot make treatment decisions for themselves.

Some states or territories have specific legislation governing the informed consent of children and adolescents in healthcare. It is the responsibility of all healthcare providers to know and understand their legal obligations in whichever state or territory they are practising. For further information, consult your state/territory legislation and/or consult your professional indemnity insurer or professional association.

Scoring

PARENT/CAREGIVER SUB-SCALE

Use the parent sub-scale where the adolescent cannot exercise decision-making control of their healthcare decisions.

0 = Optimal

1. The parent/caregiver is motivated and capable of participating fully in the recommended services and supports.

2. The parent/caregiver is capable of taking an active role in supporting the adolescent to manage the condition.

1 = Positive

1. The parent/caregiver is mostly willing to accept and participate in the recommended services and support.

2. The parent/caregiver can mostly take an active role in supporting the adolescent to manage the condition.

2 = Limited or mixed

1. The parent/caregiver is unsure whether they will accept or participate in the recommended services and supports or has limited capacity to do so.

2. There is significant divergence between the parents/caregivers in the level of engagement, motivation, or ability to participate in the recommended services and supports.

3 = Minimal

1. The parent/caregiver cannot participate in the recommended services and support without considerable practical or emotional assistance.

2. Despite the adolescent requiring them, the parent/caregiver has not facilitated access to services and supports in the past due to low engagement or motivation.

4 = Disengaged

1. The parent/caregiver cannot support participation in services and supports or avoids potentially useful and available supports.

ADOLESCENT SUB-SCALE

Use the adolescent sub-scale where the adolescent can exercise decision-making control of their healthcare decisions. In most instances, when working with a mature minor (see Informed Consent Practice Point), the use of the adolescent sub-scale will be appropriate.

0 = Optimal

1. The adolescent is motivated to participate in the recommended services and support.

2. The adolescent is capable of taking an active role in managing the condition.

1 = Positive

1. The adolescent is mostly willing to accept and participate in the recommended services and support.

2. The adolescent can mostly take an active role in managing the condition.

2 = Limited

1. The adolescent is hesitant to accept and participate in the recommended services and support.

3 = Minimal

1. The adolescent is very reluctant to accept or participate in services and support.

2. The adolescent has not participated in services and support in the past, despite requiring them, due to low levels of engagement or motivation.

4 = Disengaged

1. The adolescent refuses to accept or participate in the recommended services and support.