“My day is already planned out before I even get to choose it”: Using youth-oriented research to understand and measure what matters to youth ages 12-15 and the implications for mental health design and evaluation

“My day is already planned out before I even get to choose it”: Using youth-oriented research to understand and measure what matters to youth ages 12-15 and the implications for mental health design and evaluation | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article “My day is already planned out before I even get to choose it”: Using youth-oriented research to understand and measure what matters to youth ages 12-15 and the implications for mental health design and evaluation Skye Pamela Barbic, Cassia Warren, Kirsten Marchand, Taite Beggs, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6753127/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 10 Nov, 2025 Read the published version in Child Psychiatry & Human Development → Version 1 posted 9 You are reading this latest preprint version Abstract Voices and experiences of youth ages 12–15 are rarely heard and prioritized. Understanding their perspectives is essential for tailoring effective mental health interventions and supports. As such, this qualitative study, co-designed with a youth advisory committee (n = 7), interviewed 19 youth (ages 12–15) to explore their understanding of good mental health. Interviews were analyzed thematically following a reflexive thematic analysis approach. Three overarching themes were identified: 1) Everything is OK , describing a state of being able to manage the challenges of life, 2) Building Personal Strength and Resources , needed to maintain good mental health as an adolescent, and 3) Seeking Acceptance and Community , emphasizing the profound influence of social connections. Addressing adolescent mental health effectively requires a nuanced understanding of their perspectives to develop responsive and impactful mental health interventions and their active involvement in all facets of service design, research, and policymaking. Adolescents integrated youth services youth mental health youth advisory committee qualitative research Introduction Mental health disorders emerge early, with three-quarters of conditions manifesting by the age of 24(McGorry et al., 2024 ), and the average age of onset occurring at just 14.5 years(Patel et al., 2015 ; Solmi et al., 2022 ). This early onset, coupled with the substantial burden mental health challenges placed on youth globally (defined here as ages 12–24), highlights the urgent need to engage young people as active partners in mental health research, service design, and implementation (Hawke, Darnay, Relihan, et al., 2020 ). While much of the focus to date has been on involving youth ages 16–24 in these areas, adolescents ages 12–15 often encounter the mental health care system for the first time during this period. This makes the 12–15 age range a critical juncture for health system administrators and policy makers to focus on for delivering effective, person-centered care. Involving adolescents with lived experience ensures that services and assessments reflect what matters most to them, such as their unique perceptions of health, rather than relying solely on traditional metrics or biomarkers that may overlook the complexities of their daily lives. Furthermore, adolescent partners in care planning are instrumental in promoting person-centered language (Henderson et al., 2018 ), fostering destigmatization (Aguirre Velasco et al., 2020 ), and increasingly contributing to the training (Freedman et al., 2023 ) and implementation of measurement-based mental health care (Barbic et al., 2022 ; Freedman et al., 2023 ). Their involvement is essential to shaping services that truly meet their needs and have lasting, meaningful impact. Adolescents in the 12–15-year range experience a confluence of biological, psychological, and social changes that significantly influence their mental health (McGorry et al., 2024 ; Solmi et al., 2022 ). This period is marked by rapid physical development, hormonal fluctuations, and cognitive maturation, which lead to increased self-awareness and new explorations of identity (McGorry, 2022 ; Waddell et al., 2007 ). Additionally, social dynamics shift as peer relationships become paramount, which can introduce pressures related to acceptance, belonging, and self-esteem (Ow et al., 2024 ). The desire for autonomy often conflicts with parental and educational expectations (Ben-David et al., 2022 ), creating the potential for stress and emotional turmoil (Kalinyak et al., 2016 ). Furthermore, this age group is increasingly exposed to digital interactions (Loades et al., 2024 ; Zenone et al., 2021 ), which can impact self-image and social skills (Cinelli et al., 2020 ; Zenone et al., 2020 ). Understanding these unique developmental needs is essential for addressing mental health challenges in this population and empowering youth, families/caregivers, service providers, and decision makers to design services that are tailored to their developmental and mental health needs. In Canada, there has been significant investment in mental health services for youth ages 12–24 years through a model called Integrated Youth Services (IYS). IYS are innovative, comprehensive support systems designed to address the multifaceted needs of youth, including mental health, primary care, substance use, social services (e.g., work, education, housing), and peer support (Mathias et al., 2022 ; McGorry et al., 2022 ). Although evidence for the model is emerging (Henderson et al., 2023 ; McGorry et al., 2022 ), one noted gap in service delivery is how best to support youth ages 12–15 years. In British Columbia (BC), 12- to 15-year-olds make up 18% of the population accessing IYS (Foundry) (2018–2023 data), with this age group representing 26% of total visits last fiscal year (Mathias et al., 2022 ). In Ontario, youth in this age group represent 28% of all youth accessing IYS (Youth Wellness Hubs Ontario) in the last year (Henderson, personal communication). Despite the expansion of IYS across Canada, a deeper understanding of this 12–15 age group is essential to ensure that services are effectively tailored to meet their unique needs and optimize impact. To our knowledge, no IYS study thus far has involved youth ages 12–15 in co-designing research methods or leading research activities (e.g., interviews, focus groups). Recent research highlights that engaging youth as partners in academic research projects offers many benefits for youth and the team leading the work (Ben-David et al., 2022 ; Ludlow et al., 2023 ), including improving the ecological validity of the research and ultimately leading to improved value and impact for practice and policy (Ding et al., 2023 ; Hawke, Darnay, Relihan, et al., 2020 ; Hawke et al., 2018 ). This qualitative study seeks to identify the fundamental components of "good mental health" for youth ages 12–15 and inform the development of more effective services for this population. Methods Study Design. We conducted a qualitative interview study, employing reflective thematic analysis (Braun & Clarke, 2019 ), with youth ages 12–15 across BC, Canada. This approach allowed us to deeply explore the perspectives of young people within this age group, providing rich insights into their experiences and needs related to mental health care (Braun & Clarke, 2019 ). This study was designed following the principles of the Strategy for Patient-Oriented Research (SPOR) Patient Engagement and INNOVATE frameworks (Canadian Institutes for Health Research, 2015 ; Hawke, Darnay, Brown, et al., 2020 ; Hawke, Darnay, Relihan, et al., 2020 ). We used learnings and guiding principles of these frameworks to foster engagement throughout the study by providing inclusiveness, adequate support and flexibility, mutual respect, and co-building through authentic decision making. Youth partners and study participants were recruited through Foundry, an IYS initiative. Between November 2021 and April 2022, at the time of participant recruitment, there was 13 open centres throughout the province and a virtual service, spanning all five regional health authorities that are responsible for delivering and managing health care services within their geographic area. In November 2021, we recruited seven youth ages 12–15 with attention to age, gender, and geographic diversity to take part in a Youth Advisory Committee (YAC). YAC members did not require any experience in research; we selected youth keen to learn and comfortable speaking about mental health. The YAC was supported by the research coordinator (author [anonymized for peer review]), who provided onboarding to the project, continuous relationship building, and training. Under the guidance of the research coordinator (author [anonymized]), the YAC collaborated with the research team to develop the research question, interview guide, and recruitment strategy and materials from the beginning of the project. Three Youth Research Assistants (YRAs), ages 15–18, were hired later in the project (authors [anonymized]), including one who was also a member of the YAC (author [anonymized for peer review]). The YRAs facilitated the interviews and supported various research activities (e.g., transcription, coding, dissemination of research findings), upon extensive training and supervision by the research coordinator (author [anonymized]). Training materials developed by author [anonymized for peer review] were used to train YRAs on interview and coding approaches. The YAC and YRAs also collaborated on results interpretation and outlined key messages for the manuscript and other knowledge translation activities, including co-facilitating two conference workshops. Participants. We used purposeful sampling (Palinkas et al., 2015 ) to recruit youth ages 12–15 from across the province of BC and the age range. We recruited youth through social media on the Foundry accounts (Instagram, Facebook) and reposted on individual Foundry centres’ social media accounts. Interested participants were asked to contact the research coordinator (author [anonymized for peer review]) via email and had an initial phone call to confirm their eligibility and spots available within their age group, five per age category. The consent in BC is not determined by age, but rather the ability to understand the risks and significance of the research (Secretariat on Responsible Conduct of Research, 2024); mature minor criteria was used to determine the capability of the participant to provide consent. To determine if a participant met the mature minor criteria, the research coordinator ([anonymized for peer review]) walked through the consent form slowly, prompting discussion for the youth to describe the study purpose in their own words, why they wanted to participate, and identifying how the risks and benefits could impact them. A secondary call was conducted with the participant, and, if necessary, with their guardian, to review the consent form and provide verbal consent. Data Collection. Data collection commenced in April 2022 and concluded in July 2022. We asked participants to complete an optional demographic survey online prior to the interview. Individual semi-structured interviews were co-facilitated by at least two YRAs, with oversight by the research coordinator, and conducted virtually using Zoom. Participants received a $ 40 honorarium for their participation. Recruitment ended when we reached the desired number of participants by age category. Participants were asked to reflect broadly on the key components of “good mental health,” then elaborate on factors affecting their mental health using a visual ruler (Supplemental Appendix1). A "ruler" of mental health was chosen as a grounding visual representation for reflections on poor versus good mental health and impacts on their mental health, where participants could express their responses by moving up and down on the ruler. In the first phase of the interview, participants were asked to define good mental health. In the second phase of the interview, participants were asked to describe what it looked and felt like to be at the worst possible (0) and best possible (10) mental health state on the ruler, what factors could cause them to move up or down, and where they were on the ruler during the day of the interview. The third phase of the interview focused on recovery, which involved asking participants to describe what recovery meant to them, what their short- and long-term goals for their well-being were, and what supports would help them reach those goals. The results for the third phase of the interview will be reported elsewhere. Data Analysis. All data were stored on secure encrypted servers and [anonymized]’s Zoom platform, storing data within their servers. We audio-recorded and transcribed the interviews using Zoom’s transcription feature. Authors [anonymized] cleaned the initial transcripts by editing and removing identifying information. Authors [anonymized] used an inductive approach to create verbatim codes from the transcripts using NVivo14 to manage, analyze, and visualize the data. With the research question “What is needed for youth ages 12–15 to have good mental health?” guiding the analysis, Braun and Clarke’s reflective thematic analysis method (Braun & Clarke, 2006 , 2014 ) was used to derive and consolidate themes. As this was an exploratory study embedding the principles of SPOR, the participant responses and YAC guided theme development. Specifically, codes were grouped and clustered to create initial themes. These initial themes, using participant language, were brought to the YAC to be validated, refined, and discussed to finalize the key themes and understand the story of the data. Of note, the YRAs, who were trained in qualitative research methods, played a central role in guiding the theme development, supported by ongoing training on reflexivity and social positionality to ensure an awareness of their influence on the research. Our team members regularly engaged in reflexive practices, considering how their own backgrounds and experiences might shape the interpretation of data, while recognizing the importance of social positionality in understanding the perspectives of youth participants. The YAC was actively involved in all stages, including the development of the interview guide, where they suggested age-appropriate questions that resonated with their experiences. They also contributed to the analysis by suggesting codes and offering insights into how the themes should be framed, ensuring the findings were grounded in the lived experiences of youth. To maintain rigor, we employed strategies such as triangulation, member checks, and a clear audit trail throughout the study. Results Nineteen youth participated. The pre-interview demographic survey results are listed in Table 1 . Participants were between the ages of 12–15 (median age 14) and were located in four out of five regional health authorities in BC. Eight youth (42%) identified as a man, six (32%) as a woman, four (21%) as gender fluid, and one person did not provide a response. We identified three common themes that depict the key components for what “good mental health” means to the participants – Everything is OK ; Building Personal Strength and Resources ; and Seeking Acceptance and Community . Table 1 Demographics of the adolescent participants (n = 19) Characteristics* Total (n = 19) % Age (years) 12 4 21.1 13 4 21.1 14 4 21.1 15 7 36.8 Gender identity Woman 6 31.6 Man 8 42.1 Genderfluid 4 21.1 No Response 1 5.3 Ethnicity* Indigenous, Black, or Person of Color 6 31.6 White 13 68.4 Additional Ethnicities 2 10.5 Health Authority Region Vancouver Coastal Health 5 26.3 Fraser Health 9 47.4 Island Health 3 15.8 Northern Health 2 10.5 Interior Health 0 0.0 Self-Rated Health Excellent 2 10.5 Very Good 7 36.8 Good 6 31.6 Fair 3 15.8 Poor 0 0.0 No response 1 5.3 Self-Rated Mental Health Excellent 0 0.0 Very Good 4 21.1 Good 8 42.1 Fair 2 10.5 Poor 4 21.1 No response 1 5.3 Demographics were captured pre-interview in an online survey. *Participants could identify as more than one ethnicity. Everything is OK. Most participants described the concept of being "OK" as having good mental health. They described a state of being able to manage the challenges of life, including the ability to regulate their emotions. They recognized a need to have balance over their emotions and that good mental health does not mean always being on the high end of the ruler but rather in a place and mindset to process the negatives without sliding down their mental health ruler towards “bad” mental health. Participants articulated the struggle between the expectation to be independent and maintain good mental health and needing to “just deal with things around [them]” (P06) amidst various challenging circumstances, including school and family pressures. They expressed the difficulties of navigating this transitional phase—whether entering middle or high school or stepping into young adulthood—while trying to juggle multiple pressures unique to being a 12- to 15-year-old. “Probably like when you're able to react to certain situations responsibly and respond to certain situations with strength and not so much having a smile on your face, but just having good thoughts in your head, having a good attitude towards things, being able to cope with certain things, being able to handle stressful situations.” (P04) Participants characterized mental health as a continuous process of striving to cope and stay in a place of Everything is OK during a crucial developmental phase. One behavior they identified as a key indicator of poor mental health was to "bottle it up or bury emotions" (P08). They reported experiencing a buildup of stressors in their environment, which often had detrimental effects on their mental well-being. This overwhelming pressure frequently resulted in negative thoughts, heightened anxiety, low motivation, and an inability to effectively process the challenges they faced. Furthermore, participants noted that feeling overwhelmed and the tendency to suppress emotions sometimes manifested in irritability or uncharacteristic rudeness. In an effort to avoid upsetting others, many participants reported that they often isolated themselves, leading to feelings of loneliness. Participants also reported that this emotional strain produced physical symptoms, ranging from nail-biting and fidgeting to headaches and, in more severe cases, panic attacks. Throughout all interviews, participants underscored the intricate relationship between emotional and physical health during this critical developmental stage. “Sometimes you find yourself stuck and you just don't know how to feel you don't know how to respond to things. I know several times in my life, I just haven't felt good and I couldn't identify why. And so that's not so much having a meltdown, but, it's trying to identify feelings? And, I think that temporarily, you've lost that ability to do that. And sometimes even you don't know how you feel. And so it can be anywhere between not feeling nothing to feeling all of the feelings and feeling it all, or, just losing everything and just. But usually for me, having... it's kind of like having a panic attack. Your adrenaline goes way up, and your heartbeat goes up, and your brain is alerted? That's kind of what having an episode to me means? It's kind of like losing your sanity, if that makes sense.” (P04) Another youth described the impact of bottling up emotions on their judgement and ability to navigate day to day activities. “It feels like, kind of everything is crushing down, every single memory from the past or every single worry from the future or every single thing that's happened in like a lifetime just crushing down on you and making everything miserable. And like, where you would be like a normal sense we can like, think of like the good things and the bad, you're just thinking like only about the bad things and not in like a sense, where you can properly judge what's happening.” (P15) Most participants emphasized that mindset is fundamental to maintaining a state of Everything is OK They highlighted the importance of having a clear mind and being equipped to handle ongoing stressors while pursuing new interests and passions. Participants in this age group recognized the significance of being attuned to their own mindset as well as the mindsets of those around them. They stressed the necessity of intentionally creating space to process various sources of information and allowing personal time for recovery. “There's, ah, nothing wrong with life, I like my friends, I like reality, but like, sometimes it's just fun to take a break from it.” (P07) “Doing something I'm passion[ate] about, or doing a hobby, or, helping out in the community, um, or sometimes you're in a good mood, but you're just wanting to be alone, and enjoy that for yourself.” (P04) Opposite to Everything is OK , participants reported feeling out of control and often avoiding activities that typically bring them joy, such as spending time with friends or engaging in school. Many described this state as a challenging cycle that is difficult to break or move back up the ruler towards good mental health, leading to intense negative emotions such as anger and sadness. One participant highlighted how this struggle underscores the urgent need for supportive strategies to help adolescents regain control and reconnect with the activities that foster their well-being. “Probably not like, maybe not like moving a lot, maybe just like really, really tired, for some reason, or like not talking to people like avoiding conversations, and like putting, like no effort into anything.” (P13) Building Personal Strength and Resources. This theme highlights the essential personal strength and resources needed to maintain good mental health and foster personal growth. It encompasses the cultivation of skills necessary for navigating current and future challenges, as well as the knowledge of how and where to access appropriate support systems. All participants talked about the importance of having outlets for stress and emotions, including the need to learn better communication skills, “so that you don’t bottle it in” (P01). Meaningful activity and joy were described as critical by participants. When having a bad day, participants described the importance of spending time doing something they are passionate about to improve their mindset. One participant noted, “when I get home, I'll grab my longboard and just go for a ride before I do my homework because then my mind is clear and I'm not fogged from the day” (P01). Participants described other meaningful activities important to their mental health such as grounding activities (e.g., breathing exercises, connecting to nature), reflection activities (e.g., journaling, talking to others including family and friends), distracting activities (e.g., reading a book, playing video games), comforting activities (e.g., taking warm showers, eating good food), and releasing activities (e.g., sports, exercise, going into the woods to let off steam and scream). Doing these activities was described as cultivating their ability to get back to a positive mindset and their ability to manage life challenges and have good mental health. Beyond how youth spend their day, autonomy was viewed as important to all participants. They described being in a unique stage of life and the need to develop coping tools to be independent. Participants expressed that being unable to engage in activities negatively impacts their mental health. One youth described that “ my day is already planned out before I get to choose it” (P07), highlighting how the lack of control over their time impacts their ability to explore the things they enjoy and diminishes their well-being. They noted that the “accumulation of a lot of things” (P11) being asked of them that are out of their control pushed them out of a state of good mental health. In this state, small things were often described to grow into big things that felt impossible to overcome. “Well, my mom wants me to do all these things, while I'm still doing the one thing she asked me to do.” (P05) “Sometimes doing really simple chores can just lead to self-destructive habits. Just like, doing something stressful and it feels like such a huge overwhelming task that you just can't complete, because it just seems it's like, it's like a huge boulder that you're trying to push up a hill. ” (P03) Many youth described personal coping tools, but also a need to navigate a complicated mental health system that is often hard to access independently. For example, talking through feelings was a tool identified as improving their mental health. Some participants found it helpful to talk with counsellors, while others felt that they had nowhere to go and did not want to open up to strangers based on past experiences or experiences of their friends. Participants stressed the importance of peers who had similar experiences to guide them in decision making. “Therapy” was viewed by many as something that was forced on them or others, and something participants often did not feel that they had control to participate in or not. “I know a lot of people would say like talking about my feelings, but that did not help for me, because I was forced into that, and that made me think about it as a bad thing, and it is good to talk about your feelings, um, but for me it wasn't very good, because I was forced into that, and it helped to stop .” (P09) Youth continuously described the need for their voices to be truly heard. They wanted access to more and better resources connected to trusted spaces, such as school and community centers — noting that they sometimes are not allowed to seek supports outside of areas familiar to their parents. They recognized that everyone may need and want different types of supports and having choice is critical to gain trust in those supports and in themselves. Seeking Acceptance and Community. This theme highlights the profound influence that social connections have on adolescent well-being and internal acceptance. Participants identified both the positive and negative impacts of those around them, noting feelings of rejection stemming from judgment, bullying, or harassment, contrasted with the comfort of being accepted by those with whom they can truly be themselves. Although self-acceptance is fundamentally an internal process, participants acknowledged that it is significantly influenced by their connections with others. Participants indicated they felt higher on the mental health ruler when they " liked themselves " (P15), while their mental health declined when they experienced " low self-esteem or a lot of insecurities " (P08). Youth described how receiving “validation from others” (P04), such as positive words or compliments or seeing successes like a “ good grade ” (P18) or “ winning a big game ” (P12), moved them up the mental health ruler. “It's easier to feel good about yourself when other people like feel good about you or think you look good, I don't know just getting compliments and having people be nice to you just feels good, and kind of keeps you craving that feeling of like not wanting to kill yourself.” (P16) The ability to have a positive sense of self was reported by participants to be severely impacted by bullying and harassment in their environments, particularly in schools, which they identified as a significant threat to their mental health each day. All participants regarded these issues as among the most critical risks to long-term well-being for themselves and adolescents around them. Participants consistently highlighted that bullying and harassment not only negatively affected their mental health but also led many of their peers to feel as though their very existence was invalid, severely impacting their self-acceptance at school and in other places (e.g., on sports teams/clubs, at home). Participants noted experiences of being ridiculed for their weight or skin color, enduring transphobic remarks, and not knowing how to respond when witnessing others experience bullying. Participants emphasized an urgent need for effective interventions and support systems that address the pervasive nature of bullying and its profound impact on mental health and daily functioning to be embedded in their day-to-day environments. Participants said that these feelings are exacerbated when there is a lack of safe spaces or people, or when teachers fail to notice or step in. One youth said the following in response to what moves them down the ruler towards poor mental health: “Just kind of to stay aware of what other people are talking about because the amount of things that the kids say, and get slipped by like, you know, um saying racial slurs or something like that or you know like things that come off as teasing. Which, in actuality isn't and they're just making fun of you. Like today even there was a kid going like this [mimics holds arm to chest and shaking] to make to make fun of a kid that had, like, special needs. And because the teacher wasn't looking, nothing was done and no one said anything. And it just—to have just an extra awareness that kids do that kind of thing when you're not looking so you should probably just try to pay a little bit more attention.” (P1) Participants described how constant bullying to them or others around them can often lead to worries about being judged, social anxiety, feeling stuck and hopeless, and even leading to self-harming behaviors. “A big part of like my mental health is like my body image. So like I'm either, when I'm like a really low, I’m either like ‘I'm horrible I should never eat again, like I'm just going to eat broccoli every day for the rest of my day’, so I started like going really down in weight or I'm like ‘I'm already bad anyway so who cares, let’s eat ice cream cake, everything, we don't care, it's bad anyway’ so like. Yes, and like I isolate myself because, like I don't know I feel like shame and guilt around it and I don't really want people to see me like this, so I like isolated myself .” (P11) To foster good mental health, participants emphasized the need to surround themselves with trusted individuals who make them feel heard and understood, enabling them to express themselves authentically. Many participants articulated the critical importance of having supportive people " by my side” (P17) no matter what, underscoring how vital these connections are for improving mental health throughout the adolescent period. Participants described how social relationships change frequently during the developmental years of 12–15, requiring ongoing efforts to create, re-create, or test safe spaces for emotional expression and personal growth. When asked to describe being on the high end of the mental health ruler, participants described being more likely to smile, laugh, and be goofy, and were more open, energetic, and talkative with people around them. Participants reported feeling higher on the mental health ruler when their relationships were positive and lower when conflicts arose. Having people in their corner creates a safe environment for participants to express themselves — talking about negative things in their life, or even just spending time together, can brighten their mood and move them up the ruler. However, in close relationships trust and acceptance can be a double-edged sword. Validation from these close relationships reduces the effects of negative interactions with others, but rejection from those they trust most can be detrimental to their mental health, as one youth described: “People I consider close to me kind of mistreating me or leaving, like I had a really close friend who I had been friends with for 14 years and they started to treat me really poorly and when I told them about it, I was like ‘hey I don't feel great about that’, they kind of just kept doing it and kept insulting me about it. And after that my mental health gone to a really, really dark place.” (P16) Some participants highlighted the times that adolescents actively hide from social connection. One participant mentioned that they sometimes desire to be alone because they feel like no one is there for them, or they do not want to burden those around them with their problems. Other participants described how being around others in a bad mood can bring everyone else down and did not want to be the cause of that for others. “I think like my family like I can really talk to them and they can help me, but then with my friends, I don't like I don't really want to talk about my problems, because I feel like they already have like their own problems, and I feel like if I talked about it with my problems they're going to have like even more problems and they already have enough, so I don't want to like overwhelm [them].” (P11) Despite moments of pushing back and wanting to be isolated, many participants noted that they consistently rely on their support systems to help them break free from negative cycles and elevate their mental health. They expressed a deep desire to feel supported and reassured that their friends and family will accept them during their lowest points. Participants highlighted the importance of engaging in conversations with friends, teachers, and family, participating in enjoyable activities together for distraction, and, at times, simply receiving a comforting hug. Participants noted that connections are vital not only for emotional support, but also to create a sense of belonging throughout this period of development. “I don't really think there's a lot people can do when you're in that mind space, except be there and you know, like reassure that you are there for them, and just have a good support group. But, I’m not overly sure on how, to be a better support group, other than just like being supportive, and I don’t know, kind to the person who's struggling.” (P16) Participants described relationships as a resource for maintaining their mental well-being and support them in getting back to a state of Everything is OK while Building Personal Strength and Resources. Discussion This study aimed to understand the key components of youths’ (ages 12–15) mental health and the factors shaping their mental health experiences by employing patient-oriented methods. Our thematic analysis identified three themes that shaped participants’ understanding of their mental health journey: Everything is OK , Building Personal Strength and Resources , and Seeking Acceptance and Community . The findings collectively underscore the critical impact of environment and autonomy on youths’ mental health and their ability to cultivate skills and spaces to express themselves. Participants noted that this life stage is pivotal and complex, highlighting a need to incorporate the voices of today’s 12- to 15-year-olds in the creation of services that are truly effective in meeting their rapidly changing needs. While extensive research has focused on critical transition periods for youth (Addington et al., 2018 ; Feldman-Sparber, 2016 ; Nochajski & Schweitzer, 2014 ), such as the shift from high school to post-secondary education and adulthood, our study offers a novel perspective by addressing mental health during the earlier stages of adolescence. Participants underscored the significance of their environments and peer relationships, highlighting how these elements create a supportive space essential for navigating the complexities of their lives, including seeking out mental health support. Participants indicated that their key sources of influence were predominantly found within school and family settings, a finding that aligns with existing literature (Ben-David et al., 2022 ; McGorry et al., 2024 ; Virk et al., 2022 ). Participants articulated a pressing need for resources in their environments (school, home) to facilitate open dialogue and understanding about mental health in adolescence. By shining a light on these early developmental stages, our findings call for a shift in focus within mental health research and service delivery, advocating for interventions that not only address the immediate challenges adolescents face, but integrate with their environment and the ever-changing circumstances around them. Despite the well-established understanding of the central role that schools play in adolescents' lives, the integration of mental health services within school settings, or in complementary ways, remains relatively uncommon. Schools serve as primary environments for social interaction, academic learning, and personal development, thus positioning them as critical venues for promoting mental health (Boyle et al., 2024 ; Loades et al., 2024 ; McGorry et al., 2024 ). However, the integration of mental health supports can be hindered by insufficient funding and resources, as well as a predominant focus on academic outcomes, including standardized testing and the evolving demands of the curriculum (Lanfredi et al., 2019 ; Loades et al., 2024 ). Consequently, the effective incorporation of mental health services into the educational framework may necessitate systemic changes in some places, such as enhancing funding and encouraging a cultural shift in attitudes towards mental health support for youth across their lifetime. Future research with youth in decision-making roles is essential to investigate how embedded mental health and wellness services (e.g., school counselors, peer support workers, embedded IYS staff) can simultaneously improve adolescents' educational experiences, access to mental health resources, and overall mental health outcomes. It is critical that these services are co-designed with youth to offer an array of clinical and non-clinical supports (i.e., peer support or activity-based programs) to give choice and ensure they meet diverse needs and preferences. Our results align with other Canadian-led studies (Ding et al., 2023 ; Hawke et al., 2018 ; Henderson et al., 2023 ; Quinlan-Davidson et al., 2021 ) that emphasize the importance of prioritizing adolescent voices when determining key mental health outcomes, methods of delivering care, and approaches to measuring quality in care settings. The rapid changes that adolescents experience—alongside risk factors such as peer pressure, academic stress, social justice, climate change, and identity formation—underscore the urgency of this approach (Panchal et al., 2021 ; Quinlan-Davidson et al., 2021 ; Radez et al., 2021 ). As noted by Allemang and colleagues (Allemang et al., 2023 ), these changes go "hand-in-hand," highlighting the interconnectedness of their developmental journey and mental health needs. It is imperative that researchers, service leaders, and policymakers integrate these insights into the design and implementation of mental health services to ensure they are relevant, accessible, and supportive for adolescents navigating this critical stage of life. As models such as IYS expand to serve more youth in the 12–24 age group, it is crucial to avoid a one-size-fits-all approach and consider the unique needs of younger adolescents in the process of planning care. Our study is not without limitations. Individuals in our sample must have accessed the recruitment posts online, meaning they may have more awareness and heath seeking behavior. Additionally, we could not include individuals who had limited or no access to the internet or were unable to participate due to parental supervision of online interactions. Another unexpected challenge with online recruitment was the number of individuals who were non-youth and/or outside of BC (or even Canada) who attempted to falsely represent themselves in order to participate in the study and receive an honorarium. To counter the risks, we worked closely with the local ethics board to build in processes to screen out false participants in a safe and confidential manner. The types of questions that could be asked in the study were limited by the online environment and study protocols, including targeted questions around poor mental health. We were also limited in the methods we could use (1:1 interviews only). Working with adolescents takes time and careful attention to ethical procedures and engagement methods, including informed consent/assent, confidentiality, and other ways of sharing information (e.g., text, arts-based). The YAC and YRAs were critical in creating an inclusive environment where adolescents could feel safe and empowered to share their experiences in an online environment, enhancing the validity of content, relatability, and trust. This included working with our YAC to co-design the interview guide and ensure our research team was utilizing age-appropriate language, giving participants the choice to remain off camera, and using culturally- and developmentally-relevant materials to facilitate understanding and encourage open dialogue. As suggested by the YAC, incorporating choice on the digital platform allowed participants to express their views creatively and dynamically (e.g., using chat function, dialogue), ensuring that their voices are heard. Furthermore, the YAC suggested establishing clear channels (e.g., emails, calls) for communicating the study outcomes back to youth participants, which shows them how their input directly influences research. We recommend that future studies prioritize including their population of interest as part of their research process, as it brings immense depth and perspective to the research. Involving adolescents in research design is time-intensive and requires a strong focus on developing shared values, principles, and trust; as such, their contribution does represent a time and financial expenditure that must be incorporated into the study plan. Conclusion This study sheds light on the critical mental health concerns of adolescents ages 12–15, emphasizing the necessity of engaging this demographic in the design and evaluation of mental health services. Through a patient-oriented approach, we identified three core themes, Everything is OK , Building Personal Strength and Resources , and Seeking Acceptance and Community , which underscore the complex realities adolescents face during this pivotal stage of development. Our findings reinforce the importance of incorporating adolescent voices into mental health discourse, particularly in recognizing the unique risk factors encountered such as peer pressure, academic stress, and identity formation. The study also underscores the importance of involving youth in research and carving out the time and resources required for meaningful engagement. While our findings are limited by the small sample size and the specific geographical context of one Canadian province, they offer a foundational understanding of the mental health needs of this age group. Future research should seek to expand these insights, exploring broader demographic contexts and employing diverse methodologies to deepen our understanding, including arts-based methods. Ultimately, integrating the perspectives of adolescents into mental health service design and evaluation is imperative for creating effective, accessible, and supportive interventions that resonate with their lived experiences. Declarations Acknowledgements We would like to express our gratitude to the members of the Youth Advisory Committee (YAC) including Roryann Woodburn, Noah Davies, Bella Fox, Maya Parmar, and others. This work would not have been as rich without their valuable insights and direction. Declaration of conflicting interest The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Funding statement. Funding was received by Providence Research for this research through a donation made possible by the Carraresi Foundation Early Career Clinician Investigator Award. Ethical approval and informed consent statements This study was approved by the University of British Columbia (UBC) Behavioral Ethics Research Board (#H21-02907). Informed consent was received from all participants. Data availability statement. The qualitative data generated during this study are available upon request, with access granted only to researchers with ethical clearance, and all shared data will be anonymized to protect participant confidentiality. References Addington J, Goldstein BI, Wang JL, Kennedy SH, Bray S, Lebel C, Hassel S, Marshall C, MacQueen G (2018) Youth at-risk for serious mental illness: methods of the PROCAN study. 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BMJ Open 11(5):e044929. https://doi.org/10.1136/bmjopen-2020-044929 Radez J, Reardon T, Creswell C, Lawrence PJ, Evdoka-Burton G, Waite P (2021) Why do children and adolescents (not) seek and access professional help for their mental health problems? A systematic review of quantitative and qualitative studies. Eur Child Adolesc Psychiatry 30(2):183–211. https://doi.org/10.1007/s00787-019-01469-4 Secretariat on Responsible Conduct of Research (n.d.). Consent and capacity . Government of Canada. https://ethics.gc.ca/eng/policy-politique_interpretations_consent-consentement.html Solmi M, Radua J, Olivola M, Croce E, Soardo L, Salazar de Pablo G, Il Shin J, Kirkbride JB, Jones P, Kim JH, Kim JY, Carvalho AF, Seeman MV, Correll CU, Fusar-Poli P (2022) Age at onset of mental disorders worldwide: large-scale meta-analysis of 192 epidemiological studies. Mol Psychiatry 27(1):281–295. https://doi.org/10.1038/s41380-021-01161-7 Virk P, Arora R, Burt H, Gadermann A, Barbic S, Nelson M, Davidson J, Cornish P, Doan Q (2022) HEARTSMAP-U: Adapting a Psychosocial Self-Screening and Resource Navigation Support Tool for Use by Post-secondary Students. Front Psychiatry 13:812965. https://doi.org/10.3389/fpsyt.2022.812965 Waddell C, McEwan K, Peters RD, Hua JM, Garland O (2007) Preventing mental disorders in children: a public health priority. Can J Public Health 98(3):174–178 Zenone M, Irving P, Cianfrone M, Lockhart L, Costales S, Cruz K, Ignacio J (2020) Increasing Awareness of a Provincial Mental Health Resource for Boys and Young Men 12 to 17 Years: Reflections From Foundry’s Province-Wide Campaign. Health Promot Pract 1524839920910695. https://doi.org/10.1177/1524839920910695 Zenone M, Ow N, Barbic S (2021) TikTok and public health: a proposed research agenda. BMJ Glob Health 6(11). https://doi.org/10.1136/bmjgh-2021-007648 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 10 Nov, 2025 Read the published version in Child Psychiatry & Human Development → Version 1 posted Editorial decision: Revision requested 22 Aug, 2025 Reviews received at journal 02 Aug, 2025 Reviews received at journal 21 Jul, 2025 Reviewers agreed at journal 07 Jul, 2025 Reviewers agreed at journal 23 Jun, 2025 Reviewers invited by journal 18 Jun, 2025 Editor assigned by journal 29 May, 2025 Submission checks completed at journal 28 May, 2025 First submitted to journal 26 May, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6753127","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":473261467,"identity":"5ba7ea0c-9b0f-464e-a0fa-05156a6f89e9","order_by":0,"name":"Skye Pamela Barbic","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA1ElEQVRIiWNgGAWjYDACHiBmbGBgMGBmYHwAYpCkhdmARC0MDGwSRGmR7zlj+IBxh12+OTvzs2reHXYM/O0H8GsxONtjbMB4JtlyZzOb2W3eM8kMEmcSCGjh5zGTYGxjNjA4zMN2m7ftANCFBLTI9/OY/2BsqwdrKQZr4X9AwDNne8wYGNsOg7Uwg7VIEHLYmWPFEolnjhtYNrMZS849k8wjcYOALfI9yRs/fNxRbWDOf/jhh7c77OT4+wnYwsDAgepfHkLqgYCdgDtGwSgYBaNgFAAAt588vZ7mRwYAAAAASUVORK5CYII=","orcid":"","institution":"University of British Columbia","correspondingAuthor":true,"prefix":"","firstName":"Skye","middleName":"Pamela","lastName":"Barbic","suffix":""},{"id":473261468,"identity":"27b0915c-11b9-4ac1-b3cb-71c0a72d02af","order_by":1,"name":"Cassia Warren","email":"","orcid":"","institution":"Providence Health Care","correspondingAuthor":false,"prefix":"","firstName":"Cassia","middleName":"","lastName":"Warren","suffix":""},{"id":473261469,"identity":"51c68e93-2a18-4c22-a4a7-5c55517801d4","order_by":2,"name":"Kirsten Marchand","email":"","orcid":"","institution":"University of British Columbia","correspondingAuthor":false,"prefix":"","firstName":"Kirsten","middleName":"","lastName":"Marchand","suffix":""},{"id":473261470,"identity":"baa5a3ec-6781-4322-9e9d-b0abfc91ef38","order_by":3,"name":"Taite Beggs","email":"","orcid":"","institution":"University of British Columbia","correspondingAuthor":false,"prefix":"","firstName":"Taite","middleName":"","lastName":"Beggs","suffix":""},{"id":473261471,"identity":"99960cfc-9c73-4d23-a77e-2b48b6e7235f","order_by":4,"name":"Sonya Tsou","email":"","orcid":"","institution":"University of British Columbia","correspondingAuthor":false,"prefix":"","firstName":"Sonya","middleName":"","lastName":"Tsou","suffix":""},{"id":473261472,"identity":"a2c11b8e-7490-451a-b853-3bab477baa09","order_by":5,"name":"Benjamin Smit","email":"","orcid":"","institution":"University of British Columbia","correspondingAuthor":false,"prefix":"","firstName":"Benjamin","middleName":"","lastName":"Smit","suffix":""},{"id":473261473,"identity":"c9a1d29c-d599-4e79-bb5d-18edb4db5685","order_by":6,"name":"Leah Lockhart","email":"","orcid":"","institution":"Providence Health Care","correspondingAuthor":false,"prefix":"","firstName":"Leah","middleName":"","lastName":"Lockhart","suffix":""},{"id":473261474,"identity":"4140cad7-feb7-4e57-bb50-bb8178b877c9","order_by":7,"name":"Roxanne Turuba","email":"","orcid":"","institution":"University of British Columbia","correspondingAuthor":false,"prefix":"","firstName":"Roxanne","middleName":"","lastName":"Turuba","suffix":""},{"id":473261475,"identity":"edbc9657-c2b1-4e3f-ba4a-306869490d99","order_by":8,"name":"Steve Mathias","email":"","orcid":"","institution":"Providence Health Care","correspondingAuthor":false,"prefix":"","firstName":"Steve","middleName":"","lastName":"Mathias","suffix":""},{"id":473261476,"identity":"4408a56b-7382-42a1-a5e4-d3cbcd0c12ca","order_by":9,"name":"Shelly Ben-David","email":"","orcid":"","institution":"University of British Columbia - Okanagan Campus","correspondingAuthor":false,"prefix":"","firstName":"Shelly","middleName":"","lastName":"Ben-David","suffix":""}],"badges":[],"createdAt":"2025-05-26 18:08:18","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6753127/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6753127/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s10578-025-01926-z","type":"published","date":"2025-11-10T15:57:34+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":96105030,"identity":"ff7f78dd-e7f9-4f7d-a050-8209ae480bf7","added_by":"auto","created_at":"2025-11-17 16:07:33","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":690321,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6753127/v1/66d8a0ee-cdc8-4e80-83af-03cea17ebd2b.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"“My day is already planned out before I even get to choose it”: Using youth-oriented research to understand and measure what matters to youth ages 12-15 and the implications for mental health design and evaluation","fulltext":[{"header":"Introduction","content":"\u003cp\u003eMental health disorders emerge early, with three-quarters of conditions manifesting by the age of 24(McGorry et al., \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2024\u003c/span\u003e), and the average age of onset occurring at just 14.5 years(Patel et al., \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2015\u003c/span\u003e; Solmi et al., \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). This early onset, coupled with the substantial burden mental health challenges placed on youth globally (defined here as ages 12\u0026ndash;24), highlights the urgent need to engage young people as active partners in mental health research, service design, and implementation (Hawke, Darnay, Relihan, et al., \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). While much of the focus to date has been on involving youth ages 16\u0026ndash;24 in these areas, adolescents ages 12\u0026ndash;15 often encounter the mental health care system for the first time during this period. This makes the 12\u0026ndash;15 age range a critical juncture for health system administrators and policy makers to focus on for delivering effective, person-centered care. Involving adolescents with lived experience ensures that services and assessments reflect what matters most to them, such as their unique perceptions of health, rather than relying solely on traditional metrics or biomarkers that may overlook the complexities of their daily lives. Furthermore, adolescent partners in care planning are instrumental in promoting person-centered language (Henderson et al., \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2018\u003c/span\u003e), fostering destigmatization (Aguirre Velasco et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2020\u003c/span\u003e), and increasingly contributing to the training (Freedman et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2023\u003c/span\u003e) and implementation of measurement-based mental health care (Barbic et al., \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Freedman et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Their involvement is essential to shaping services that truly meet their needs and have lasting, meaningful impact.\u003c/p\u003e \u003cp\u003eAdolescents in the 12\u0026ndash;15-year range experience a confluence of biological, psychological, and social changes that significantly influence their mental health (McGorry et al., \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Solmi et al., \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). This period is marked by rapid physical development, hormonal fluctuations, and cognitive maturation, which lead to increased self-awareness and new explorations of identity (McGorry, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Waddell et al., \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2007\u003c/span\u003e). Additionally, social dynamics shift as peer relationships become paramount, which can introduce pressures related to acceptance, belonging, and self-esteem (Ow et al., \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). The desire for autonomy often conflicts with parental and educational expectations (Ben-David et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2022\u003c/span\u003e), creating the potential for stress and emotional turmoil (Kalinyak et al., \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). Furthermore, this age group is increasingly exposed to digital interactions (Loades et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Zenone et al., \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e2021\u003c/span\u003e), which can impact self-image and social skills (Cinelli et al., \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Zenone et al., \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Understanding these unique developmental needs is essential for addressing mental health challenges in this population and empowering youth, families/caregivers, service providers, and decision makers to design services that are tailored to their developmental and mental health needs.\u003c/p\u003e \u003cp\u003eIn Canada, there has been significant investment in mental health services for youth ages 12\u0026ndash;24 years through a model called Integrated Youth Services (IYS). IYS are innovative, comprehensive support systems designed to address the multifaceted needs of youth, including mental health, primary care, substance use, social services (e.g., work, education, housing), and peer support (Mathias et al., \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; McGorry et al., \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Although evidence for the model is emerging (Henderson et al., \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; McGorry et al., \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2022\u003c/span\u003e), one noted gap in service delivery is how best to support youth ages 12\u0026ndash;15 years. In British Columbia (BC), 12- to 15-year-olds make up 18% of the population accessing IYS (Foundry) (2018\u0026ndash;2023 data), with this age group representing 26% of total visits last fiscal year (Mathias et al., \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). In Ontario, youth in this age group represent 28% of all youth accessing IYS (Youth Wellness Hubs Ontario) in the last year (Henderson, personal communication). Despite the expansion of IYS across Canada, a deeper understanding of this 12\u0026ndash;15 age group is essential to ensure that services are effectively tailored to meet their unique needs and optimize impact.\u003c/p\u003e \u003cp\u003eTo our knowledge, no IYS study thus far has involved youth ages 12\u0026ndash;15 in co-designing research methods or leading research activities (e.g., interviews, focus groups). Recent research highlights that engaging youth as partners in academic research projects offers many benefits for youth and the team leading the work (Ben-David et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Ludlow et al., \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2023\u003c/span\u003e), including improving the ecological validity of the research and ultimately leading to improved value and impact for practice and policy (Ding et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Hawke, Darnay, Relihan, et al., \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Hawke et al., \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). This qualitative study seeks to identify the fundamental components of \"good mental health\" for youth ages 12\u0026ndash;15 and inform the development of more effective services for this population.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cb\u003eStudy Design.\u003c/b\u003e We conducted a qualitative interview study, employing reflective thematic analysis (Braun \u0026amp; Clarke, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2019\u003c/span\u003e), with youth ages 12\u0026ndash;15 across BC, Canada. This approach allowed us to deeply explore the perspectives of young people within this age group, providing rich insights into their experiences and needs related to mental health care (Braun \u0026amp; Clarke, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). This study was designed following the principles of the Strategy for Patient-Oriented Research (SPOR) Patient Engagement and INNOVATE frameworks (Canadian Institutes for Health Research, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2015\u003c/span\u003e; Hawke, Darnay, Brown, et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Hawke, Darnay, Relihan, et al., \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). We used learnings and guiding principles of these frameworks to foster engagement throughout the study by providing inclusiveness, adequate support and flexibility, mutual respect, and co-building through authentic decision making. Youth partners and study participants were recruited through Foundry, an IYS initiative. Between November 2021 and April 2022, at the time of participant recruitment, there was 13 open centres throughout the province and a virtual service, spanning all five regional health authorities that are responsible for delivering and managing health care services within their geographic area.\u003c/p\u003e \u003cp\u003eIn November 2021, we recruited seven youth ages 12\u0026ndash;15 with attention to age, gender, and geographic diversity to take part in a Youth Advisory Committee (YAC). YAC members did not require any experience in research; we selected youth keen to learn and comfortable speaking about mental health. The YAC was supported by the research coordinator (author [anonymized for peer review]), who provided onboarding to the project, continuous relationship building, and training. Under the guidance of the research coordinator (author [anonymized]), the YAC collaborated with the research team to develop the research question, interview guide, and recruitment strategy and materials from the beginning of the project. Three Youth Research Assistants (YRAs), ages 15\u0026ndash;18, were hired later in the project (authors [anonymized]), including one who was also a member of the YAC (author [anonymized for peer review]). The YRAs facilitated the interviews and supported various research activities (e.g., transcription, coding, dissemination of research findings), upon extensive training and supervision by the research coordinator (author [anonymized]). Training materials developed by author [anonymized for peer review] were used to train YRAs on interview and coding approaches. The YAC and YRAs also collaborated on results interpretation and outlined key messages for the manuscript and other knowledge translation activities, including co-facilitating two conference workshops.\u003c/p\u003e \u003cp\u003e\u003cb\u003eParticipants.\u003c/b\u003e We used purposeful sampling (Palinkas et al., \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2015\u003c/span\u003e) to recruit youth ages 12\u0026ndash;15 from across the province of BC and the age range. We recruited youth through social media on the Foundry accounts (Instagram, Facebook) and reposted on individual Foundry centres\u0026rsquo; social media accounts. Interested participants were asked to contact the research coordinator (author [anonymized for peer review]) via email and had an initial phone call to confirm their eligibility and spots available within their age group, five per age category. The consent in BC is not determined by age, but rather the ability to understand the risks and significance of the research (Secretariat on Responsible Conduct of Research, 2024); mature minor criteria was used to determine the capability of the participant to provide consent. To determine if a participant met the mature minor criteria, the research coordinator ([anonymized for peer review]) walked through the consent form slowly, prompting discussion for the youth to describe the study purpose in their own words, why they wanted to participate, and identifying how the risks and benefits could impact them. A secondary call was conducted with the participant, and, if necessary, with their guardian, to review the consent form and provide verbal consent.\u003c/p\u003e \u003cp\u003e \u003cb\u003eData Collection.\u003c/b\u003e Data collection commenced in April 2022 and concluded in July 2022. We asked participants to complete an optional demographic survey online prior to the interview. Individual semi-structured interviews were co-facilitated by at least two YRAs, with oversight by the research coordinator, and conducted virtually using Zoom. Participants received a \u003cspan\u003e$\u003c/span\u003e40 honorarium for their participation. Recruitment ended when we reached the desired number of participants by age category. Participants were asked to reflect broadly on the key components of \u0026ldquo;good mental health,\u0026rdquo; then elaborate on factors affecting their mental health using a visual ruler (Supplemental Appendix1). A \"ruler\" of mental health was chosen as a grounding visual representation for reflections on poor versus good mental health and impacts on their mental health, where participants could express their responses by moving up and down on the ruler. \u003c/p\u003e \u003cp\u003e In the first phase of the interview, participants were asked to define good mental health. In the second phase of the interview, participants were asked to describe what it looked and felt like to be at the worst possible (0) and best possible (10) mental health state on the ruler, what factors could cause them to move up or down, and where they were on the ruler during the day of the interview. The third phase of the interview focused on recovery, which involved asking participants to describe what recovery meant to them, what their short- and long-term goals for their well-being were, and what supports would help them reach those goals. The results for the third phase of the interview will be reported elsewhere.\u003c/p\u003e \u003cp\u003e \u003cb\u003eData Analysis.\u003c/b\u003e All data were stored on secure encrypted servers and [anonymized]\u0026rsquo;s Zoom platform, storing data within their servers. We audio-recorded and transcribed the interviews using Zoom\u0026rsquo;s transcription feature. Authors [anonymized] cleaned the initial transcripts by editing and removing identifying information. Authors [anonymized] used an inductive approach to create verbatim codes from the transcripts using NVivo14 to manage, analyze, and visualize the data. With the research question \u0026ldquo;What is needed for youth ages 12\u0026ndash;15 to have good mental health?\u0026rdquo; guiding the analysis, Braun and Clarke\u0026rsquo;s reflective thematic analysis method (Braun \u0026amp; Clarke, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2006\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2014\u003c/span\u003e) was used to derive and consolidate themes. As this was an exploratory study embedding the principles of SPOR, the participant responses and YAC guided theme development. Specifically, codes were grouped and clustered to create initial themes. These initial themes, using participant language, were brought to the YAC to be validated, refined, and discussed to finalize the key themes and understand the story of the data.\u003c/p\u003e \u003cp\u003eOf note, the YRAs, who were trained in qualitative research methods, played a central role in guiding the theme development, supported by ongoing training on reflexivity and social positionality to ensure an awareness of their influence on the research. Our team members regularly engaged in reflexive practices, considering how their own backgrounds and experiences might shape the interpretation of data, while recognizing the importance of social positionality in understanding the perspectives of youth participants. The YAC was actively involved in all stages, including the development of the interview guide, where they suggested age-appropriate questions that resonated with their experiences. They also contributed to the analysis by suggesting codes and offering insights into how the themes should be framed, ensuring the findings were grounded in the lived experiences of youth. To maintain rigor, we employed strategies such as triangulation, member checks, and a clear audit trail throughout the study.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eNineteen youth participated. The pre-interview demographic survey results are listed in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Participants were between the ages of 12\u0026ndash;15 (median age 14) and were located in four out of five regional health authorities in BC. Eight youth (42%) identified as a man, six (32%) as a woman, four (21%) as gender fluid, and one person did not provide a response. We identified three common themes that depict the key components for what \u0026ldquo;good mental health\u0026rdquo; means to the participants \u0026ndash; \u003cem\u003eEverything is OK\u003c/em\u003e; \u003cem\u003eBuilding Personal Strength and Resources\u003c/em\u003e; and \u003cem\u003eSeeking Acceptance and Community\u003c/em\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographics of the adolescent participants (n\u0026thinsp;=\u0026thinsp;19)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristics*\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;19)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e21.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e21.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e21.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e36.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender identity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWoman\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e31.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMan\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e42.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGenderfluid\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e21.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo Response\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEthnicity*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIndigenous, Black, or Person of Color\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e31.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWhite\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e68.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdditional Ethnicities\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHealth Authority Region\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVancouver Coastal Health\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e26.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFraser Health\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e47.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIsland Health\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNorthern Health\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInterior Health\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSelf-Rated Health\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExcellent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVery Good\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e36.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e31.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFair\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePoor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo response\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSelf-Rated Mental Health\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExcellent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVery Good\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e21.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e42.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFair\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePoor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e21.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo response\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eDemographics were captured pre-interview in an online survey.\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e*Participants could identify as more than one ethnicity.\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eEverything is OK.\u003c/b\u003e Most participants described the concept of being \"OK\" as having good mental health. They described a state of being able to manage the challenges of life, including the ability to regulate their emotions. They recognized a need to have balance over their emotions and that good mental health does not mean always being on the high end of the ruler but rather in a place and mindset to process the negatives without sliding down their mental health ruler towards \u0026ldquo;bad\u0026rdquo; mental health.\u003c/p\u003e \u003cp\u003eParticipants articulated the struggle between the expectation to be independent and maintain good mental health and needing to \u003cem\u003e\u0026ldquo;just deal with things around [them]\u0026rdquo;\u003c/em\u003e (P06) amidst various challenging circumstances, including school and family pressures. They expressed the difficulties of navigating this transitional phase\u0026mdash;whether entering middle or high school or stepping into young adulthood\u0026mdash;while trying to juggle multiple pressures unique to being a 12- to 15-year-old.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Probably like when you're able to react to certain situations responsibly and respond to certain situations with strength and not so much having a smile on your face, but just having good thoughts in your head, having a good attitude towards things, being able to cope with certain things, being able to handle stressful situations.\u0026rdquo;\u003c/em\u003e (P04)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eParticipants characterized mental health as a continuous process of striving to cope and stay in a place of \u003cem\u003eEverything is OK\u003c/em\u003e during a crucial developmental phase. One behavior they identified as a key indicator of poor mental health was to \u003cem\u003e\"bottle it up or bury emotions\"\u003c/em\u003e (P08). They reported experiencing a buildup of stressors in their environment, which often had detrimental effects on their mental well-being. This overwhelming pressure frequently resulted in negative thoughts, heightened anxiety, low motivation, and an inability to effectively process the challenges they faced. Furthermore, participants noted that feeling overwhelmed and the tendency to suppress emotions sometimes manifested in irritability or uncharacteristic rudeness. In an effort to avoid upsetting others, many participants reported that they often isolated themselves, leading to feelings of loneliness. Participants also reported that this emotional strain produced physical symptoms, ranging from nail-biting and fidgeting to headaches and, in more severe cases, panic attacks. Throughout all interviews, participants underscored the intricate relationship between emotional and physical health during this critical developmental stage.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Sometimes you find yourself stuck and you just don't know how to feel you don't know how to respond to things. I know several times in my life, I just haven't felt good and I couldn't identify why. And so that's not so much having a meltdown, but, it's trying to identify feelings? And, I think that temporarily, you've lost that ability to do that. And sometimes even you don't know how you feel. And so it can be anywhere between not feeling nothing to feeling all of the feelings and feeling it all, or, just losing everything and just. But usually for me, having... it's kind of like having a panic attack. Your adrenaline goes way up, and your heartbeat goes up, and your brain is alerted? That's kind of what having an episode to me means? It's kind of like losing your sanity, if that makes sense.\u0026rdquo;\u003c/em\u003e (P04)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAnother youth described the impact of bottling up emotions on their judgement and ability to navigate day to day activities.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;It feels like, kind of everything is crushing down, every single memory from the past or every single worry from the future or every single thing that's happened in like a lifetime just crushing down on you and making everything miserable. And like, where you would be like a normal sense we can like, think of like the good things and the bad, you're just thinking like only about the bad things and not in like a sense, where you can properly judge what's happening.\u0026rdquo;\u003c/em\u003e (P15)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eMost participants emphasized that mindset is fundamental to maintaining a state of \u003cem\u003eEverything is OK\u003c/em\u003e They highlighted the importance of having a clear mind and being equipped to handle ongoing stressors while pursuing new interests and passions. Participants in this age group recognized the significance of being attuned to their own mindset as well as the mindsets of those around them. They stressed the necessity of intentionally creating space to process various sources of information and allowing personal time for recovery.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;There's, ah, nothing wrong with life, I like my friends, I like reality, but like, sometimes it's just fun to take a break from it.\u0026rdquo;\u003c/em\u003e (P07)\u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Doing something I'm passion[ate] about, or doing a hobby, or, helping out in the community, um, or sometimes you're in a good mood, but you're just wanting to be alone, and enjoy that for yourself.\u0026rdquo;\u003c/em\u003e (P04)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eOpposite to \u003cem\u003eEverything is OK\u003c/em\u003e, participants reported feeling out of control and often avoiding activities that typically bring them joy, such as spending time with friends or engaging in school. Many described this state as a challenging cycle that is difficult to break or move back up the ruler towards good mental health, leading to intense negative emotions such as anger and sadness. One participant highlighted how this struggle underscores the urgent need for supportive strategies to help adolescents regain control and reconnect with the activities that foster their well-being.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Probably not like, maybe not like moving a lot, maybe just like really, really tired, for some reason, or like not talking to people like avoiding conversations, and like putting, like no effort into anything.\u0026rdquo;\u003c/em\u003e (P13)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003eBuilding Personal Strength and Resources.\u003c/b\u003e This theme highlights the essential personal strength and resources needed to maintain good mental health and foster personal growth. It encompasses the cultivation of skills necessary for navigating current and future challenges, as well as the knowledge of how and where to access appropriate support systems.\u003c/p\u003e \u003cp\u003eAll participants talked about the importance of having outlets for stress and emotions, including the need to learn better communication skills, \u003cem\u003e\u0026ldquo;so that you don\u0026rsquo;t bottle it in\u0026rdquo;\u003c/em\u003e (P01). Meaningful activity and joy were described as critical by participants. When having a bad day, participants described the importance of spending time doing something they are passionate about to improve their mindset. One participant noted, \u003cem\u003e\u0026ldquo;when I get home, I'll grab my longboard and just go for a ride before I do my homework because then my mind is clear and I'm not fogged from the day\u0026rdquo;\u003c/em\u003e (P01). Participants described other meaningful activities important to their mental health such as grounding activities (e.g., breathing exercises, connecting to nature), reflection activities (e.g., journaling, talking to others including family and friends), distracting activities (e.g., reading a book, playing video games), comforting activities (e.g., taking warm showers, eating good food), and releasing activities (e.g., sports, exercise, going into the woods to let off steam and scream). Doing these activities was described as cultivating their ability to get back to a positive mindset and their ability to manage life challenges and have good mental health.\u003c/p\u003e \u003cp\u003eBeyond how youth spend their day, autonomy was viewed as important to all participants. They described being in a unique stage of life and the need to develop coping tools to be independent. Participants expressed that being unable to engage in activities negatively impacts their mental health. One youth described that \u0026ldquo;\u003cem\u003emy day is already planned out before I get to choose it\u0026rdquo;\u003c/em\u003e (P07), highlighting how the lack of control over their time impacts their ability to explore the things they enjoy and diminishes their well-being. They noted that the \u003cem\u003e\u0026ldquo;accumulation of a lot of things\u0026rdquo;\u003c/em\u003e (P11) being asked of them that are out of their control pushed them out of a state of good mental health. In this state, small things were often described to grow into big things that felt impossible to overcome.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Well, my mom wants me to do all these things, while I'm still doing the one thing she asked me to do.\u0026rdquo;\u003c/em\u003e (P05)\u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Sometimes doing really simple chores can just lead to self-destructive habits. Just like, doing something stressful and it feels like such a huge overwhelming task that you just can't complete, because it just seems it's like, it's like a huge boulder that you're trying to push up a hill.\u003c/em\u003e\u0026rdquo; (P03)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eMany youth described personal coping tools, but also a need to navigate a complicated mental health system that is often hard to access independently. For example, talking through feelings was a tool identified as improving their mental health. Some participants found it helpful to talk with counsellors, while others felt that they had nowhere to go and did not want to open up to strangers based on past experiences or experiences of their friends. Participants stressed the importance of peers who had similar experiences to guide them in decision making. \u0026ldquo;Therapy\u0026rdquo; was viewed by many as something that was forced on them or others, and something participants often did not feel that they had control to participate in or not.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I know a lot of people would say like talking about my feelings, but that did not help for me, because I was forced into that, and that made me think about it as a bad thing, and it is good to talk about your feelings, um, but for me it wasn't very good, because I was forced into that, and it helped to stop\u003c/em\u003e.\u0026rdquo; (P09)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eYouth continuously described the need for their voices to be truly heard. They wanted access to more and better resources connected to trusted spaces, such as school and community centers\u003cem\u003e\u0026mdash;\u003c/em\u003enoting that they sometimes are not allowed to seek supports outside of areas familiar to their parents. They recognized that everyone may need and want different types of supports and having choice is critical to gain trust in those supports and in themselves.\u003c/p\u003e \u003cp\u003e\u003cb\u003eSeeking Acceptance and Community.\u003c/b\u003e This theme highlights the profound influence that social connections have on adolescent well-being and internal acceptance. Participants identified both the positive and negative impacts of those around them, noting feelings of rejection stemming from judgment, bullying, or harassment, contrasted with the comfort of being accepted by those with whom they can truly be themselves.\u003c/p\u003e \u003cp\u003eAlthough self-acceptance is fundamentally an internal process, participants acknowledged that it is significantly influenced by their connections with others. Participants indicated they felt higher on the mental health ruler when they \"\u003cem\u003eliked themselves\u003c/em\u003e\" (P15), while their mental health declined when they experienced \"\u003cem\u003elow self-esteem or a lot of insecurities\u003c/em\u003e\" (P08). Youth described how receiving \u003cem\u003e\u0026ldquo;validation from others\u0026rdquo;\u003c/em\u003e (P04), such as positive words or compliments or seeing successes like a \u0026ldquo;\u003cem\u003egood grade\u003c/em\u003e\u0026rdquo; (P18) or \u0026ldquo;\u003cem\u003ewinning a big game\u003c/em\u003e\u0026rdquo; (P12), moved them up the mental health ruler.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;It's easier to feel good about yourself when other people like feel good about you or think you look good, I don't know just getting compliments and having people be nice to you just feels good, and kind of keeps you craving that feeling of like not wanting to kill yourself.\u0026rdquo;\u003c/em\u003e (P16)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThe ability to have a positive sense of self was reported by participants to be severely impacted by bullying and harassment in their environments, particularly in schools, which they identified as a significant threat to their mental health each day. All participants regarded these issues as among the most critical risks to long-term well-being for themselves and adolescents around them. Participants consistently highlighted that bullying and harassment not only negatively affected their mental health but also led many of their peers to feel as though their very existence was invalid, severely impacting their self-acceptance at school and in other places (e.g., on sports teams/clubs, at home). Participants noted experiences of being ridiculed for their weight or skin color, enduring transphobic remarks, and not knowing how to respond when witnessing others experience bullying. Participants emphasized an urgent need for effective interventions and support systems that address the pervasive nature of bullying and its profound impact on mental health and daily functioning to be embedded in their day-to-day environments. Participants said that these feelings are exacerbated when there is a lack of safe spaces or people, or when teachers fail to notice or step in. One youth said the following in response to what moves them down the ruler towards poor mental health:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Just kind of to stay aware of what other people are talking about because the amount of things that the kids say, and get slipped by like, you know, um saying racial slurs or something like that or you know like things that come off as teasing. Which, in actuality isn't and they're just making fun of you. Like today even there was a kid going like this [mimics holds arm to chest and shaking] to make to make fun of a kid that had, like, special needs. And because the teacher wasn't looking, nothing was done and no one said anything. And it just\u0026mdash;to have just an extra awareness that kids do that kind of thing when you're not looking so you should probably just try to pay a little bit more attention.\u0026rdquo;\u003c/em\u003e (P1)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eParticipants described how constant bullying to them or others around them can often lead to worries about being judged, social anxiety, feeling stuck and hopeless, and even leading to self-harming behaviors.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;A big part of like my mental health is like my body image. So like I'm either, when I'm like a really low, I\u0026rsquo;m either like \u0026lsquo;I'm horrible I should never eat again, like I'm just going to eat broccoli every day for the rest of my day\u0026rsquo;, so I started like going really down in weight or I'm like \u0026lsquo;I'm already bad anyway so who cares, let\u0026rsquo;s eat ice cream cake, everything, we don't care, it's bad anyway\u0026rsquo; so like. Yes, and like I isolate myself because, like I don't know I feel like shame and guilt around it and I don't really want people to see me like this, so I like isolated myself\u003c/em\u003e.\u0026rdquo; (P11)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e To foster good mental health, participants emphasized the need to surround themselves with trusted individuals who make them feel heard and understood, enabling them to express themselves authentically. Many participants articulated the critical importance of having supportive people \"\u003cem\u003eby my side\u0026rdquo;\u003c/em\u003e (P17) no matter what, underscoring how vital these connections are for improving mental health throughout the adolescent period. Participants described how social relationships change frequently during the developmental years of 12\u0026ndash;15, requiring ongoing efforts to create, re-create, or test safe spaces for emotional expression and personal growth.\u003c/p\u003e \u003cp\u003eWhen asked to describe being on the high end of the mental health ruler, participants described being more likely to smile, laugh, and be goofy, and were more open, energetic, and talkative with people around them. Participants reported feeling higher on the mental health ruler when their relationships were positive and lower when conflicts arose. Having people in their corner creates a safe environment for participants to express themselves\u003cem\u003e\u0026mdash;\u003c/em\u003etalking about negative things in their life, or even just spending time together, can brighten their mood and move them up the ruler. However, in close relationships trust and acceptance can be a double-edged sword. Validation from these close relationships reduces the effects of negative interactions with others, but rejection from those they trust most can be detrimental to their mental health, as one youth described:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;People I consider close to me kind of mistreating me or leaving, like I had a really close friend who I had been friends with for 14 years and they started to treat me really poorly and when I told them about it, I was like \u0026lsquo;hey I don't feel great about that\u0026rsquo;, they kind of just kept doing it and kept insulting me about it. And after that my mental health gone to a really, really dark place.\u0026rdquo;\u003c/em\u003e (P16)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eSome participants highlighted the times that adolescents actively hide from social connection. One participant mentioned that they sometimes desire to be alone because they feel like no one is there for them, or they do not want to burden those around them with their problems. Other participants described how being around others in a bad mood can bring everyone else down and did not want to be the cause of that for others.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I think like my family like I can really talk to them and they can help me, but then with my friends, I don't like I don't really want to talk about my problems, because I feel like they already have like their own problems, and I feel like if I talked about it with my problems they're going to have like even more problems and they already have enough, so I don't want to like overwhelm [them].\u0026rdquo;\u003c/em\u003e (P11)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eDespite moments of pushing back and wanting to be isolated, many participants noted that they consistently rely on their support systems to help them break free from negative cycles and elevate their mental health. They expressed a deep desire to feel supported and reassured that their friends and family will accept them during their lowest points. Participants highlighted the importance of engaging in conversations with friends, teachers, and family, participating in enjoyable activities together for distraction, and, at times, simply receiving a comforting hug. Participants noted that connections are vital not only for emotional support, but also to create a sense of belonging throughout this period of development.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I don't really think there's a lot people can do when you're in that mind space, except be there and you know, like reassure that you are there for them, and just have a good support group. But, I\u0026rsquo;m not overly sure on how, to be a better support group, other than just like being supportive, and I don\u0026rsquo;t know, kind to the person who's struggling.\u0026rdquo;\u003c/em\u003e (P16)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eParticipants described relationships as a resource for maintaining their mental well-being and support them in getting back to a state of \u003cem\u003eEverything is OK\u003c/em\u003e while \u003cem\u003eBuilding Personal Strength and Resources.\u003c/em\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study aimed to understand the key components of youths\u0026rsquo; (ages 12\u0026ndash;15) mental health and the factors shaping their mental health experiences by employing patient-oriented methods. Our thematic analysis identified three themes that shaped participants\u0026rsquo; understanding of their mental health journey: \u003cem\u003eEverything is OK\u003c/em\u003e, \u003cem\u003eBuilding Personal Strength and Resources\u003c/em\u003e, and \u003cem\u003eSeeking Acceptance and Community\u003c/em\u003e. The findings collectively underscore the critical impact of environment and autonomy on youths\u0026rsquo; mental health and their ability to cultivate skills and spaces to express themselves. Participants noted that this life stage is pivotal and complex, highlighting a need to incorporate the voices of today\u0026rsquo;s 12- to 15-year-olds in the creation of services that are truly effective in meeting their rapidly changing needs.\u003c/p\u003e \u003cp\u003eWhile extensive research has focused on critical transition periods for youth (Addington et al., \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Feldman-Sparber, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; Nochajski \u0026amp; Schweitzer, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2014\u003c/span\u003e), such as the shift from high school to post-secondary education and adulthood, our study offers a novel perspective by addressing mental health during the earlier stages of adolescence. Participants underscored the significance of their environments and peer relationships, highlighting how these elements create a supportive space essential for navigating the complexities of their lives, including seeking out mental health support. Participants indicated that their key sources of influence were predominantly found within school and family settings, a finding that aligns with existing literature (Ben-David et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; McGorry et al., \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Virk et al., \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Participants articulated a pressing need for resources in their environments (school, home) to facilitate open dialogue and understanding about mental health in adolescence. By shining a light on these early developmental stages, our findings call for a shift in focus within mental health research and service delivery, advocating for interventions that not only address the immediate challenges adolescents face, but integrate with their environment and the ever-changing circumstances around them.\u003c/p\u003e \u003cp\u003e Despite the well-established understanding of the central role that schools play in adolescents' lives, the integration of mental health services within school settings, or in complementary ways, remains relatively uncommon. Schools serve as primary environments for social interaction, academic learning, and personal development, thus positioning them as critical venues for promoting mental health (Boyle et al., \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Loades et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; McGorry et al., \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). However, the integration of mental health supports can be hindered by insufficient funding and resources, as well as a predominant focus on academic outcomes, including standardized testing and the evolving demands of the curriculum (Lanfredi et al., \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Loades et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Consequently, the effective incorporation of mental health services into the educational framework may necessitate systemic changes in some places, such as enhancing funding and encouraging a cultural shift in attitudes towards mental health support for youth across their lifetime. Future research with youth in decision-making roles is essential to investigate how embedded mental health and wellness services (e.g., school counselors, peer support workers, embedded IYS staff) can simultaneously improve adolescents' educational experiences, access to mental health resources, and overall mental health outcomes. It is critical that these services are co-designed with youth to offer an array of clinical and non-clinical supports (i.e., peer support or activity-based programs) to give choice and ensure they meet diverse needs and preferences.\u003c/p\u003e \u003cp\u003eOur results align with other Canadian-led studies (Ding et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Hawke et al., \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Henderson et al., \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Quinlan-Davidson et al., \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2021\u003c/span\u003e) that emphasize the importance of prioritizing adolescent voices when determining key mental health outcomes, methods of delivering care, and approaches to measuring quality in care settings. The rapid changes that adolescents experience\u0026mdash;alongside risk factors such as peer pressure, academic stress, social justice, climate change, and identity formation\u0026mdash;underscore the urgency of this approach (Panchal et al., \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Quinlan-Davidson et al., \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Radez et al., \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). As noted by Allemang and colleagues (Allemang et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2023\u003c/span\u003e), these changes go \"hand-in-hand,\" highlighting the interconnectedness of their developmental journey and mental health needs. It is imperative that researchers, service leaders, and policymakers integrate these insights into the design and implementation of mental health services to ensure they are relevant, accessible, and supportive for adolescents navigating this critical stage of life. As models such as IYS expand to serve more youth in the 12\u0026ndash;24 age group, it is crucial to avoid a one-size-fits-all approach and consider the unique needs of younger adolescents in the process of planning care.\u003c/p\u003e \u003cp\u003eOur study is not without limitations. Individuals in our sample must have accessed the recruitment posts online, meaning they may have more awareness and heath seeking behavior. Additionally, we could not include individuals who had limited or no access to the internet or were unable to participate due to parental supervision of online interactions. Another unexpected challenge with online recruitment was the number of individuals who were non-youth and/or outside of BC (or even Canada) who attempted to falsely represent themselves in order to participate in the study and receive an honorarium. To counter the risks, we worked closely with the local ethics board to build in processes to screen out false participants in a safe and confidential manner.\u003c/p\u003e \u003cp\u003eThe types of questions that could be asked in the study were limited by the online environment and study protocols, including targeted questions around poor mental health. We were also limited in the methods we could use (1:1 interviews only). Working with adolescents takes time and careful attention to ethical procedures and engagement methods, including informed consent/assent, confidentiality, and other ways of sharing information (e.g., text, arts-based). The YAC and YRAs were critical in creating an inclusive environment where adolescents could feel safe and empowered to share their experiences in an online environment, enhancing the validity of content, relatability, and trust. This included working with our YAC to co-design the interview guide and ensure our research team was utilizing age-appropriate language, giving participants the choice to remain off camera, and using culturally- and developmentally-relevant materials to facilitate understanding and encourage open dialogue. As suggested by the YAC, incorporating choice on the digital platform allowed participants to express their views creatively and dynamically (e.g., using chat function, dialogue), ensuring that their voices are heard. Furthermore, the YAC suggested establishing clear channels (e.g., emails, calls) for communicating the study outcomes back to youth participants, which shows them how their input directly influences research. We recommend that future studies prioritize including their population of interest as part of their research process, as it brings immense depth and perspective to the research. Involving adolescents in research design is time-intensive and requires a strong focus on developing shared values, principles, and trust; as such, their contribution does represent a time and financial expenditure that must be incorporated into the study plan.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study sheds light on the critical mental health concerns of adolescents ages 12\u0026ndash;15, emphasizing the necessity of engaging this demographic in the design and evaluation of mental health services. Through a patient-oriented approach, we identified three core themes, \u003cem\u003eEverything is OK\u003c/em\u003e, \u003cem\u003eBuilding Personal Strength and Resources\u003c/em\u003e, and \u003cem\u003eSeeking Acceptance and Community\u003c/em\u003e, which underscore the complex realities adolescents face during this pivotal stage of development. Our findings reinforce the importance of incorporating adolescent voices into mental health discourse, particularly in recognizing the unique risk factors encountered such as peer pressure, academic stress, and identity formation. The study also underscores the importance of involving youth in research and carving out the time and resources required for meaningful engagement. While our findings are limited by the small sample size and the specific geographical context of one Canadian province, they offer a foundational understanding of the mental health needs of this age group. Future research should seek to expand these insights, exploring broader demographic contexts and employing diverse methodologies to deepen our understanding, including arts-based methods. Ultimately, integrating the perspectives of adolescents into mental health service design and evaluation is imperative for creating effective, accessible, and supportive interventions that resonate with their lived experiences.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to express our gratitude to the members of the Youth Advisory Committee (YAC) including Roryann Woodburn, Noah Davies, Bella Fox, Maya Parmar, and others. This work would not have been as rich without their valuable insights and direction.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclaration of conflicting interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding statement.\u0026nbsp;\u003c/strong\u003eFunding was received by Providence Research for this research through a donation made possible by the Carraresi Foundation Early Career Clinician Investigator Award.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical approval and informed consent statements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the University of British Columbia (UBC) Behavioral Ethics Research Board (#H21-02907). Informed consent was received from all participants.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability statement.\u0026nbsp;\u003c/strong\u003eThe qualitative data generated during this study are available upon request, with access granted only to researchers with ethical clearance, and all shared data will be anonymized to protect participant confidentiality.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAddington J, Goldstein BI, Wang JL, Kennedy SH, Bray S, Lebel C, Hassel S, Marshall C, MacQueen G (2018) Youth at-risk for serious mental illness: methods of the PROCAN study. 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BMJ Glob Health 6(11). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1136/bmjgh-2021-007648\u003c/span\u003e\u003cspan address=\"10.1136/bmjgh-2021-007648\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"child-psychiatry-and-human-development","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"chud","sideBox":"Learn more about [Child Psychiatry \u0026 Human Development](http://link.springer.com/journal/10578)","snPcode":"10578","submissionUrl":"https://submission.nature.com/new-submission/10578/3","title":"Child Psychiatry \u0026 Human Development","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Adolescents, integrated youth services, youth mental health, youth advisory committee, qualitative research","lastPublishedDoi":"10.21203/rs.3.rs-6753127/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6753127/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eVoices and experiences of youth ages 12–15 are rarely heard and prioritized. Understanding their perspectives is essential for tailoring effective mental health interventions and supports. As such, this qualitative study, co-designed with a youth advisory committee (n = 7), interviewed 19 youth (ages 12–15) to explore their understanding of good mental health. Interviews were analyzed thematically following a reflexive thematic analysis approach. Three overarching themes were identified: 1) \u003cem\u003eEverything is OK\u003c/em\u003e, describing a state of being able to manage the challenges of life, 2) \u003cem\u003eBuilding Personal Strength and Resources\u003c/em\u003e, needed to maintain good mental health as an adolescent, and 3) \u003cem\u003eSeeking Acceptance and Community\u003c/em\u003e, emphasizing the profound influence of social connections. Addressing adolescent mental health effectively requires a nuanced understanding of their perspectives to develop responsive and impactful mental health interventions and their active involvement in all facets of service design, research, and policymaking.\u003c/p\u003e","manuscriptTitle":"“My day is already planned out before I even get to choose it”: Using youth-oriented research to understand and measure what matters to youth ages 12-15 and the implications for mental health design and evaluation","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-20 06:37:43","doi":"10.21203/rs.3.rs-6753127/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-08-22T06:46:19+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-03T00:43:24+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-21T17:28:41+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"239137656924443608952672797364679390009","date":"2025-07-07T19:49:05+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"142397239509574376415232972593066938759","date":"2025-06-23T08:40:40+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-06-18T06:58:03+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-05-30T00:57:38+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-05-28T09:14:51+00:00","index":"","fulltext":""},{"type":"submitted","content":"Child Psychiatry \u0026 Human Development","date":"2025-05-26T18:06:53+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"child-psychiatry-and-human-development","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"chud","sideBox":"Learn more about [Child Psychiatry \u0026 Human Development](http://link.springer.com/journal/10578)","snPcode":"10578","submissionUrl":"https://submission.nature.com/new-submission/10578/3","title":"Child Psychiatry \u0026 Human Development","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"de215f7b-7463-44fb-aad6-bfef48d28720","owner":[],"postedDate":"June 20th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-11-17T16:00:52+00:00","versionOfRecord":{"articleIdentity":"rs-6753127","link":"https://doi.org/10.1007/s10578-025-01926-z","journal":{"identity":"child-psychiatry-and-human-development","isVorOnly":false,"title":"Child Psychiatry \u0026 Human Development"},"publishedOn":"2025-11-10 15:57:34","publishedOnDateReadable":"November 10th, 2025"},"versionCreatedAt":"2025-06-20 06:37:43","video":"","vorDoi":"10.1007/s10578-025-01926-z","vorDoiUrl":"https://doi.org/10.1007/s10578-025-01926-z","workflowStages":[]},"version":"v1","identity":"rs-6753127","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6753127","identity":"rs-6753127","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}