Defining Success in the Transition to Adulthood

Summary

Successful transition from childhood to adulthood is context and culturally dependent. This article will review concepts of mental health and theoretical constructs of successful adulthood that suggest intentional policies and practices are developed with a specific vision of success. Parents, educators, mental health professionals and policy makers need to be cognizant of their assumptions and essential roles in these processes. Early development of illness may disrupt and alter the timelines of different developmental milestones and trajectories. It is important to discuss what “success” looks like with transitional age youth (TAY) and their family members as treatment approaches may adapt accordingly.

Introduction

Success, like beauty, is in the eye of the beholder. As such, there are many forms success can take at an individual, familial and societal level. The concept of a successful transition to adulthood is, therefore, completely context (including geographical and historical moment) and culture dependent. However, from Marcus Aurelius, a Roman Emperor in 170 AD, who told us centuries ago in his collection of Meditations, “When you arise in the morning, think of what a precious privilege it is to be alive - to breathe, to think, to enjoy, to love”¹ to Martin Luther King, Jr., who last century told us, “If you can't fly then run, if you can't run then walk, if you can't walk then crawl, but whatever you do you have to keep moving forward,”² we can see there may be a few universal concepts of what is thought to be fundamental to being a successful adult as we help transitional age youth (TAY) reach for realization and try to thrive in adulthood.

This article will first present definitions of mental health and mental illness that have evolved in the field of psychiatry. Applying a developmental lens, the author will then review several dimensions of successful young adult development that have been described in the literature. It is important to note that the assumptions articulated by these definitions and ideals represent a Western value system, often based on self-determination theory³, which postulates that three innate psychological needs--competence, autonomy, and relatedness--underlie mental health. As there is not one specific pathway to successful adulthood, and there will be tensions between personal, familial and community ambitions, it is essential that TAY, parents or guardians, clinicians, educators, and policymakers recognize, clearly articulate and evaluate their vision together and clarify common goals of “success” as this will lead us to specific treatment interventions and particular governmental and educational policies.

Historical Definition of Mental Health

Historically, mental illness was described by ancient civilizations including the Egyptians and Greeks who recognized and named hysteria and melancholy⁴. As the flagrant symptoms of mental illness are readily apparent to others, individuals with these symptoms were often seen by society in medieval times as criminals, insane or as morally corrupt. As the field of psychiatry began to develop in the late 1800's, it became more humane but was still primarily focused on understanding and treating psychopathology and deviant behavior⁴. In the early 20^th century, the fields of mental hygiene and psychology began to evolve and the concept of mental health started to be studied, though Freud is reported to have dismissed mental health as “an ideal fiction”⁵. Until after WWII, mental health had eluded definition in the literature though it was clearly more than the absence of mental illness, but little research had been done on to how to measure positive mental health.

WHO Definitions of Health, Mental Health and Quality of Life

First defined in 1946 and last modified in 1948, the World Health Organization (WHO) defined health as, “Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”⁶ As of 2014, the WHO states the following, “Mental health is defined as a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community.”⁷ To measure well-being, WHO developed a cross-cultural tool to measure the improvement in quality of life related to health care through monitoring changes in the frequency and severity of diseases. Encompassing multiple factors including positive mental and physical health, WHO defines Quality of Life as “an individual's perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns.”⁸

In the past decade, WHO has recognized that, internationally, people are reporting as much disability from disabling mental conditions as from physical conditions and that mental disorders are affecting their activities of daily living, ability to communicate, personal relationships and occupational functioning. Mental disorders rank amongst the most disabling conditions in terms of total disability-adjusted life years (DALYs), a WHO metric developed in 1990 to estimate the global burden of disease; DALYs are an estimate of how many years of life are lost due to premature death or to being in a state of poor health and disability.⁹ The WHO has issued a Mental Health Action Plan 2013-2020 to encourage world leaders to provide more comprehensive plans and services to promote mental health as well as to prevent mental disorders.¹⁰

Menninger Definition of Mental Health

At about the same time as the introduction of the WHO definition of health, a prominent U.S. psychiatrist, Karl Menninger, defined mental health as “an adjustment of human beings to the world and to each other with a maximum of effectiveness and happiness.”¹¹ The Menninger research group, led by psychologist Lester Luborsky, developed the Health-Sickness Rating Scale¹², a precursor to the DSM-IV Global Assessment of Functioning (GAF) Scale.¹³ On Luborsky's scale, a score of 80 or above reflected positive mental health which has been subsequently supported in cross-cultural settings as well.¹⁴ Of note, the GAF has recently been dropped in DSM V¹⁵ and the World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0) is proposed as an option for measuring disability.⁸

Models of Mental Health

George Vaillant⁵, a researcher who has studied a longitudinal cohort of Harvard graduates for more than 50 years, described in a review of models of mental health the following conceptualizations of mental health as:

• above normal, a mental state that is objectively desirable—as in the capacity to work and to love

• positive psychology, an early example of which was Maslow's “self-actualizing”individual¹⁶

• maturity

• emotional or social intelligence

• subjective well-being—a mental state that is subjectively experienced as happy, contented, and desired

• resilience, as in successful adaptation and homeostasis.

Most likely, it is some combination of all of the above. Vaillant described, “Of course, healthy adult development does not follow rigid rules, nor are butterflies healthier than caterpillars. Some individuals, often because of great stress, tackle developmental tasks out of order or all at once.”⁵ He recognizes attributes or skills may have different developmental trajectories and that is certainly what TAY, particularly with mental and physical problems, may experience in even more exaggerated and disparate ways that can make transition to young adulthood and mental health treatment challenging.

One personal quality that has gained significant prominence in our society in the past couple of decades is the importance of high social-emotional intelligence. Gardner described emotional intelligence as the capacity to “discern and respond appropriately to the moods, temperaments, motivations and desires of other people.”¹⁷ Goleman more explicitly defined emotional intelligence with the following criteria:

• accurate conscious perception and monitoring of one's own emotions

• modification of one's emotions so that their expression is appropriate including the capacity to self soothe anxiety, sadness and anger

• accurate recognition of and response to emotions in others

• skill in negotiating close relationships with others

• capacity for focusing emotions (motivation) on a desired goal (delayed gratification)^18,5.

Models of Positive Youth Development

Erikson¹⁹ described the developmental tasks of young adulthood of becoming independent from family and known supports (psychologically as well as physically), of developing one's identity and role in society, and of developing intimacy or relationships with others including romantic ones. These complex tasks, concretely denoted as leaving the parental home to establish one's own residence, establishing financial independence (e.g. paying one's bills), completing high school or college, moving into full-time employment, getting married, and becoming a parent, are often considered by society as key markers of adulthood but clearly vary by culture and opportunity.²⁰ These tasks which, over time, expand an individual's social circle and impact⁵, must also be accomplished against a tumultuous backdrop of rapid hormonal and brain changes in a constantly changing external environment.

In an extensive review of the developmental literature, from a strength-based approach, Scales et al.²⁰ distilled research findings from the Search Institute and the Social Development Research Group to identify 8 consensus core dimensions of successful young adult development. These include:

• physical health

• psychological and emotional well-being

• life skills,

• ethical behavior

• healthy family and social relationships

• educational attainment

• constructive educational and occupational engagement

• civic engagement.

Scales et al.²⁰ acknowledge, “No set of dimensions of developmental success, for any life stage, possibly can be entirely valid for all imaginable variations of class, gender, sexual orientation, racial-ethnic, and religious, diversities, among others.” In a separate study, the Pathways Mapping Initiative at Harvard University, also found as desired outcomes, young adults who were: effectively educated, embarked on or prepared for a productive career, physically, mentally, and emotionally healthy, active participants in civic life, and prepared for parenting.²¹

For each of the core dimensions identified by Scales et al.²⁰, assumptions were made; for example, a healthy physical or emotional state will not be free of risk or experimentation or without the normal developmental feelings of anxiety, sadness or self-doubt. Also, successful young adults develop skills to diminish risks and handle challenges typical of this life stage, such as use of alcohol and other drugs and relationship disappointments. The review also describes the Social Development Model (SDM)²² which presupposes that in order to stay on a positive developmental trajectory, TAY need to establish bonds with family, partners and peers at developmentally appropriate ages and be given prosocial opportunities to build competencies and skills in school, work and community settings over time²⁰. SDM has been extensively researched and found to predict health-related outcomes, including substance use and misuse, depression, violence, school misbehavior, and other problem behaviors.²⁰ Evolving models of SDM that focus on developmental relationships suggest a framework of more bidirectional interactions²³ that “rather than being seen as a lock-step progression of invariant stages of development neatly correlated with specific chronological ages, development [is] seen more as an evolving person-context double helix structure.”²⁰ This highlights that the process of forming developmental relationships is iterative and there are potentially multiple opportunities and timepoints to intervene to try to change a youth's trajectory in positive directions.

One purpose of identifying the core dimensions for successful young adulthood is to be able to measure and track the dimensions if educators, policy makers and government leaders establish programs for youth and positive development in the community at large. Scales et al. conclude, “This suggests that far greater intentionality in helping young people and their socializing systems deal with that shift in relationships, contexts, demands, and opportunities is vital for a successful transition to young adulthood.”²⁰ Similarly, Nagaoka et al., from the University of Chicago Consortium on Chicago School Research led a group of educators and policymakers on a report entitled: Foundations for Young Adult Success: A Developmental Framework.²⁴ They define success in young adulthood as well as underscore the developmental experiences that are necessary to build a strong foundation to navigate the transition throughout a youth's school and community experiences. Organized around the three key factors of: 1) agency, 2) an integrated identity and 3) competencies, they found self-regulation, awareness, reflection on or making meaning out of experiences and critical thinking skills were important foundations for success.²⁴ The report describes agency as one's ability to make active choices while developing competencies such as responsible decision-making and being able to collaborate with others which eventually become incorporated into an integrated identity, or a consistent internal framework across time.²⁴ This model, while proposed to address bridging the opportunity gap for youth living in impoverished urban areas, can also inform program and policy development for other vulnerable youth populations such as those with mental illness.

Implications of the Models

Vaillant posed the fundamental question: “What facets of mental health are fixed and which are susceptible to change?”²⁵ These definitions and models seem to converge on the idea that self-determination, skills to adapt to the vagaries of life, and the skills to relate to others lead to a sense of well-being and the concept of quality of life described earlier. Further, the various models lead clinicians to ponder the modifiable factors for advocacy and treatment of TAY at the individual, familial, educational and societal levels. They also point out the need for identifying specific goals, harmonization and persistent planning. Nagaoka et al. instruct in their concept paper, “Preparing all youth for meaningful, productive futures requires coordinated efforts and intentional practices by adults across all the settings youth inhabit on a daily basis.”²⁴ Young people's opportunities will vary significantly by race, socioeconomic class, but also by experiences such as hospitalizations for mental and physical illnesses and other events such as war or natural disaster. At an educational level, Nagaoka et al. suggest different institutional emphases will be needed at different developmental stages²⁴ which while obvious to child mental health workers may not be foremost on the minds of policymakers and city, state and national leaders.

How Does the Definition of Success Influence Our Treatment Approach?

As medical professionals, along with parents and educators, we may consider our task as the following, “To maximize children's functional abilities and sense of well-being, their health-related quality of life, and their development into healthy and productive adults.”²⁶ So, why is it important to articulate our vision of successful transition to adulthood for TAY? Because our vision influences our treatment goals and strategies and methods used. In helping families, we need to take a self-assessment of what our own expectations are in addition to those of the TAY patient and the TAY's family. Clinicians often help TAY take stock of their strengths and difficulties, assess where and why they may have fallen off their trajectory and reevaluate if their goals need adjustment. Facilitating creativity, such as writing music, painting or taking photographs, or technical proficiency in an area, such as cooking, electrical wiring or car engine repair may be more helpful for a particular TAY than attending college, as an example. Families play a critical role in helping TAY meet or accept altered expectations such as living in a supervised home with case managers or participating in supported employment. Clinicians will need to be able to work with a full spectrum of parenting styles, from authoritarian or over-involved parents to laissez-faire or free-range parents. As clinicians, we may hope to strike a balance but must do so with intentionality and flexibility to adapt to whatever events or crises arise and to whatever the TAY brings to the table with regard to abilities and temperament. It is crucial for all involved to have expectations for the next achievement. Without expectations and goals, failure can be a self-fulfilling prophecy for the TAY, but sometimes goals do need to be adjusted. While the early development of a mental illness may disrupt developmental trajectories and certainly alter the timelines of achieving different developmental milestones, we should not believe that youth with serious mental illnesses should expect any less quality of life. It is important, however, to discuss what “success” looks and feels like with TAY and their family members as treatment approaches may need to adapt accordingly.

Transition Age Youth, Adulthood and Beyond

Research shows that in the absence of disease, the brain continues to work well until at least age eighty.²⁷ Current neuroscience research increasingly indicates that even in adulthood the brain is plastic and learning and memory are lifelong adaptive brain processes. In their book about aging, Holland & Greenstein share, “research has shown that among people between the ages of 18 and 85, the age group that feels the greatest sense of well-being is 82-85.”²⁸ This serves to remind us that developmental trajectories may be altered as we continue to grow, learn and mature and we can continue to strive for well-being well into old age.

Conclusions

Successful transition for TAY is context and culturally dependent. It can be defined not only as preventing problems but as positive functioning in several domains including autonomy, competence and relationships. Many of the goals to be achieved are fundamental and universal for us as humans regardless of physical or mental illnesses that may develop as we age. Successful development of youth into young adulthood includes positive psychological self-perceptions and skills building with the hopes of achieving some universal societal markers. Conscious understanding and discussion of what “success” looks like with TAY and their family members as well as amongst educators, clinicians, and policy leaders can lead to the creation of intentional programs and appropriate innovative treatment approaches.

Key points.

• Successful transition from childhood to adolescence and into adulthood is context andculturally dependent.

• There may be a few universal concepts of what is thought to be fundamental to being asuccessful adult.

• Parents, educators, mental health professionals and policy makers need to be cognizantof their assumptions about what is a successful adult is and understand they playessential roles in developing policies and practices to promote this.

• It is important to discuss what “success” looks like with transitional age youth and theirfamily members as treatment approaches may adapt accordingly.