Transitional Training Program For Adolescent

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Transitional Training Program for Adolescent, Mental Health Specialty Group, OTCOC (2016)
List of contributors
Brian Fung, OTII, CPH
Cherie Wong, OTI, UCH
Fiona Wan, OTI, QMH
Linda Yau, OTI, UCH
Magdalene Poon, SOT, KCH
Peggy Nip, OTI, AHNH
Rita Ng, OTI, KCH (Convenor)
Sharon Leung, OTI, AHNH
Shiren Wong, OTI, CPH
Wallis Chan, OTI, CPH
Table of Content
Content Page
1. Definition of transitional care 1
2. Characteristic of good transition 1
3. OT roles in transitional care 3
4. Common diagnoses (problems) in adolescent psychiatry 4
4.1 Autism Spectrum Disorder 4
4.2 Attention Deficit/ Hyperkinetic Disorder 6
4.3 Psychosis 8
4.4 Mood disorders 10
4.5 School refusal 13
4.6Occupational Therapy in Adolescent Transition Programs in 15
Hong Kong
5. Outcome measures suggested for adolescent transitional training 16
program
6. Transitional training program in adolescent psychiatry 26
6.1 Pre-engagement stage 27
6.2 Engagement stage 28
6.2.1 Study/Career planning program 29
6.2.2 Vocational exploration 30
6.2.3 Vocational assessment 30
6.2.4 Pre-requisite work skills training 31
6.2.5 Career counselling 31
6.2.6 Work place experience 31
6.2.7 Community vocational programs 32
6.2.8 Cognitive assessment and remediation 33
6.2.9 Occupational lifestyle redesign program 35
6.2.10 Practical living skills training 36
6.2.11 College preparation and transition program 38
6.2.12 Interpersonal skills or social skills training program 38
6.3 Exit stage 40
1. Definition of transitional care
Adolescence is a transitional period between childhood and adulthood.

Youth with special health care needs receive the services necessary to make
transitions to all aspects of adult life, including adult health care, work and
independence (Oswald 2013).
Transition service has been defined in the Individuals with Disabilities

Education Act (IDEA) 2006 as follow: Transition services refer to a
coordinated set of activities for child with a disability. It is designed to be within
a results-oriented process, which focuses on improving the academic and
functional achievement, so as to facilitate the student’s move from school to
post-school activities. The post-school activities include: post-secondary
education, vocational education, integrated employment (including supported
employment), continuing and adult education, adult services and independent
living or community participation. The transition service is based on the
individual child’s needs, taking into account the child’s strengths, preferences
and interests. Transition service should also include instruction, related
services, community experiences, the development of employment and other
post-school adult living objectives. The acquisition of daily living skills and
functional vocational evaluation should also include if appropriate.
Therefore, it is the process to enhance independence and autonomy by

searching for one’s confidence and self-identification. Furthermore, transition
care should be specialized and based on the individual’s medical,
psychosocial and educational/vocational needs.
2. Characteristics of good transition
Adolescents with psychiatric illnesses like Autism Spectrum Disorder

(ASD), Attention Deficit/ Hyperactivity Disorder (AD/HD) , Anxiety Disorder,
Depression and Psychosis share similar characteristics such as social
impairment, disorganized lifestyle and functional impairment in learning, which
can ultimately result in school refusal. These adolescents show poor
motivation in study, social withdrawal, chaotic lifestyle, and a lack of life goals.
A better and effective transition can reduce their likelihood of developing more
psychiatric symptoms, which can be resulted in adult psychiatric care. For
cases require continuous care, a good transition can encourage treatment
compliance from child and adolescent mental health service to adult mental
health services.
Oswald (2013) identified several factors that contributed to successful

transition. He noticed that youth were more likely to make a successful
transition if they had a mother with college education and had received all the
routine preventive care they needed in their childhood. Meanwhile, if the
doctors or other health care providers had listened carefully to them and to
their parents, a smooth transition to adulthood may be enhanced. Gender
difference also contributed to a good transition. Female will have a better
transition as compared to male. In addition, financial support by insurance
plays another important role in the transition.
Oswald also identified some determinants associated with a successful

transition. They were perspectives of stakeholders, age limits on Child and
Adolescent service, complexity of health conditions, lack of experienced
professionals in the adult arena and health care financing for chronic and
complex condition. Moreover, multi-disciplinary and inter-agency approach
was more desirable for an effective transitional care. The transition plan
should be an early intervention with the youth centre and include the
parents/caregivers. A transition plan should aim to be comprehensive, flexible
and responsive for the youth in need. It is better to develop a holistic-medical,
psychosocial and education/vocational aspect which developmentally and
age-appropriate for the youth.
To conclude, there are five factors associated with favorable

transitional outcomes. They are 1) Vocational competence and employment
perspective, 2) Implementing evidence-based practice that promote
independence, social competence, self-determination and self-advocacy, 3)
Parental involvement, 4) School and community inclusion and 5) Post-
secondary education.
3. OT roles in transitional care
Occupational therapists (OT) have expertise in technology, task and

work analysis, behavior and psychosocial needs, sensory processing, and
independent living skills, which prepares them to assume a vital role in
transition planning for students. In addition, OT works collaboratively with
other disciplines to share resources and responsibility in facilitating the
implantation of the student’s goals and plans.
According to American Occupational Therapy Association (2008), OT

takes part in transitional care in following forms:
1) Prepare the student, family and community agency representatives for

changes in roles and routines
2) Educate the family, school staff and community on diverse needs of the
child
3) Evaluate supports for employment and/or further education through role
assessment and activity analysis
4) Facilitate skills for employment and/or further education and adult living
skills
5) Support self-determination skills for successful community integration
6) Enhance social integration in the community
7) Assist with community mobility, recommending modifications and
equipment
8) Collaborate with the transition team to coordinate adult health care
resources and promote self-advocacy skills
4. Common Diagnoses (problems) in Adolescent Psychiatry
In 2016, the common diagnoses for cases aged from 12 to 18 receiving

service in Hospital Authority Child and Adolescent psychiatry are: Autism
Spectrum Disorder, Attention Deficit/Hyperkinetic Disorder, Psychosis,
Mood disorders, and Anxiety Disorders. Besides, school refusals cases may
also require medical attention. The related medical, psychosocial and
educational/vocational needs which require transitional attention are
covered in the below sections.
4.1 Autism Spectrum Disorder (ASD)
There is little research about how the social and psychological factors
of ASD impact individuals during the transition. Adolescents with ASD lack
interpersonal skills such as understanding personal space, reading facial
expressions and body language and ability to maintain conversations.
Individuals with ASD continue to have significant challenges in all
environments related to social interaction and communication in adolescence
and adulthood. Youth with ASD have potential for career success but they
require very intensive support on job and social skills. Therefore, transition
from school to adulthood continues to be a major issue for young people with
ASD.
According to University Grants Committee, 2% of students with

disability were reported to be suffering from ASD in the year of 2014 – 2015 in
Hong Kong. The students might be under care of counselor who assists them
in adjusting the environmental transition from secondary school to university.
There are disability service managers in Chinese University of Hong Kong.
They provide counseling service and related trainings. In addition, schools
provide flexible academic measures such as special examination
arrangements, learning aids / equipment, and individual and group coaching
on study skills and learning strategies. Orienteering and induction programme
for new students are introduced to facilitate their transition to college life.
Wehman (2014) pointed out that adolescents with ASD may have less
positive outlooks, lower rates of self-determination and satisfaction, enjoy low
level of personal autonomy, lack of independence in family and have less
confidence in making their own decisions. They are less likely to have a
strong sense of affiliation at school, be involved in activities or rely on friends.
They also have low participation in post-secondary education and competitive
employment. They tend to work in temporary, low wage, low skills positions,
or will be laid off or fired at a high rate. As a result, it is more likely for them to
keep being financially dependent on their parents and prone to score the
highest rate of “no engagement since high school” among all disability
categories.
The employment rates for individuals with ASD, regardless of

intellectual ability, ranged between 4.1% and 11.8% (Wehman, 2014). In
Hong Kong, the employment rate of people with ASD was about 32.6 % as
indicated by a household survey for persons with disabilities and chronic
diseases by HKSAR in 2014. Another survey conducted by Heep Hong
Society in 2015 indicated that for those adolescent with ASD ever been
employed, about 50% of sustained the job placement for 3 months or less.
Only 30% of adolescents with ASD were currently employed and maintained
their job over a year. Transition from youth to adult and engaging in a job
would be a difficult task for youth with ASD. Stable mood, good self-
management, and low rates of problematic behavior are important
considerations in securing employment for youth with ASD. Moreover, youth
with ASD who have completed college have reported significant challenges
with underemployment and chronic unemployment. Cimera and Cowan (2009)
stated that the adults with ASD worked fewer hours and earned less in wages
per week than adults with other disabilities, nearly half of the young adults
with ASD did not participate in either work or education.
Career awareness, community experience, parental involvement, study

program, self-advocacy, and self-determination and self-care/independent
living, social skills, student support for the transition, vocational education and
work study are some evidence-based predictors of post-school success in
employment. Strickland et al. (2013) designed a transition to employment
program for individuals with ASD. The program targeted to train the
participants’ job interviewing skills. It proved that the youth with ASD showed
significant improvements in their job interviewing skills after receiving some
career coaching and counseling. It not only teaches verbal and non-verbal
skills training; but also promotes understanding of the reasons for these
behaviors.
Wehman and Schall (2014) stated some best practices particularly

related to employment for youth with ASD. These practices include
identification of the most appropriate work settings and placements, provision
of effective on the job supports, provision of long term support services for the
employer and the employees with ASD, and recognition for the positive effects
of employment on individuals with ASD. A successful transition requires
continuous care for the youth with ASD.
Besides the Hospital Authority service, the non-government

organizations in Hong Kong also have some pilot projects for youth and young
adults with ASD such as 真色珍我 run by SAHK and iREACH program by
New Life Psychiatric Association The training content includes social skill
training, school accommodation, career planning and fine motor training, etc
4.2 Attention Deficit/Hyperkinetic Disorder (ADHD)
The prevalence rates of ADHD in children and adolescents were high

with an estimation of 5.3% to 5.9 % worldwide (Leung et al., 2008) and there
was still an increasing trend. ADHD was reported to be the second most
common disability reported by college students (Faigel, 1995).
Halmoy et al. (2009) reported that only 24% of adults with ADHD were
gainfully employed compared with 79% of population-based controls.
Furthermore, Barkley & Fischer (2011) stated that adolescent with ADHD
might encounter impairments in various life activities especially occupational
functioning. They might have lower occupational status and annual salaries;
worse employer-rated job performance; more job dismissals and they
changed their jobs more often. They are also less adequate in fulfilling work
demands; less likely to work independently and to complete tasks; less likely
to get along well with supervisors. They usually have poorer performances at
job interviews and may find certain tasks at work too difficult for them (Barkley
at el., 2008). Children with ADHD frequently have one or more comorbid
psychiatric disorders. About half of the youth diagnosed with ADHD also meet
diagnostic criteria for Oppositional Defiant Disorder or Conduct Disorder.
About 30% of the youth with ADHD have Anxiety Disorder, and about 25% of
them had mood disorder (Biederman, 2005). Learning disabilities, tic
disorders, and sleep disorders and disturbances are other problems frequently
seen in children with ADHD (Barkley, 2003). Hence, transition from student
role to worker role would inevitably be difficult to most of the teenagers with
ADHD.
ADHD is seen as a deficit in behavioural inhibition, sustained attention

and executive function (Barkley, 1998). As children with ADHD progress from
childhood to adolescence and into adulthood, hyperactivity tends to decrease
while problems with inattention, distractibility and executive functions
remained (Nadeau, 2005). Both attention and executive functions had a direct
effect on workplace performance (Dipeolu at el., 2013; Nadeau, 2005).
Problems that an ADHD adolescent might encounter in workplace

included poor concentration on work tasks; poor time management skills;
organizational problems of difficulty in scheduling and prioritizing tasks
(Nadeau, 2005). Moreover, barriers in reading, writing and processing
information might hinder them from following instructions (Dipeolu at el., 2013).
The problems resulting from the dysfunction affected both social and
occupational functioning, i.e. irresponsibility and negligence at work
(Hartmann, 2002; Wender, 2000), lower work performance, tasks
incompletion and unsuccessful occupational attainment (Young, 2002). These
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deficits might further influence their career maturity, career goals and work
competence. Students with ADHD might present with lower self-efficacy and
poorer self-image compared to normal teens. Due to those unique
characteristics in ADHD students, they might find it difficult to handle issues
with vocational identity, career decision-making and the career exploration
process. Dipeolu at el. (2013) concluded that teenagers with ADHD might
struggle with their vocational identity; had less career maturity and had higher
chance of having dysfunctional career thoughts due to insufficient meta-
cognitive ability. All of these factors contribute to a lower vocational readiness
in adolescents with ADHD. Although vocational rehabilitation referrals are not
common in this population currently, an increasing trend is predicted.
In recent few years, adult ADHD has been studied and transition to
adult ADHD service may be seen in the near future in Hong Kong.
4.3 Psychosis
Psychosis affected up to 1% of the population and the annual incidence

rate was 5 in 10,000 in Hong Kong (Hospital Authority, 2012). It was
estimated that over 2000 individuals develop psychosis for the first time
annually. In 2001, World Health Organization’s (WHO) World Health Report
ranked psychosis the third most disabling amongst all medical conditions.
The first psychosis episode typically occurs during a critical

developmental life stage in terms of personality, social role, educational or
vocational achievement. Onset of schizophrenia during childhood and early
adolescence, seriously disrupts developmental trajectories in educational,
social and vocational domains and it is often associated with a more severe
form of illness and poor outcome than those adult onset psychosis (Malla and
Payne, 2005).
Social and functional outcomes in psychosis were frequently reported

to be poor. Social recovery as assessed by using the Time Use Survey (TUS)
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assessing the average hours per week spend on structured activities such as
work, education, voluntary work, housework, childcare and leisure, and sport.
The survey had a cut off of 45 hours per week indicated for good social
functioning. The result of TUS of adolescents with psychosis revealed an
average of 25.97 hours per week while that of the non-clinical sample was
63.5 hours per week (Hodgekins et al, 2015). The result concluded that
adolescent suffered from psychosis spent significantly less time in structured
activities. And it would inevitably impair their development of social and
functional performance.
A 5 years follow up study reported that only 25.5% of people with

psychosis could maintain the role function as paid employment, attending
school (at least half of the time) or home maker (Robinson et al, 2004). In
Hong Kong, the employment rate for people with psychosis aged 18-64 was
33.4% as cited by a household survey for persons with disabilities and chronic
diseases by Census and Statistic Department in 2014. It is evidenced that
people with psychosis faced a lot of challenges in employment. While
employment rate had been frequently identified as a predictor for functional
recovery, service to enhance employability should be addressed.
For adolescent onset psychotic cases, there is evidence that the

diagnosis of early onset (onset before 18 years of age) psychosis predicts
lower educational achievement, less independence both economically and
emotionally, lower rate of employment, poor social relationship, and a
continuing need of psychiatric care than adult onset psychosis (Clemmenser,
2012).
In Hong Kong, a territory wide, phase specific service program for

people aged 15-24 with psychosis, named Early Assessment Service for
Young People with Psychosis (EASY), was launched in 2001. A study was
carried out with 700 participants aged 15-25 (Chang, Tang et al, 2012). The
results showed that, by the end of the 3-year follow up, 58.8% and 17.4% met
the criteria of symptomatic remission and recovery respectively. Of those who
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achieved sustainable symptomatic remission, only 43.1% were in functional
recovery. It can be predicted that adolescent with psychosis experienced a
lot of difficulties in their transition. A number of early intervention services had
established in past decade. Clinical outcome and functional outcome was
reported to be improved. However, not much service had been targeted on
enhancing the adolescent transition. Inclusion of intervention that promotes
functional recovery especially in terms of employment, education or training
should be focused. As periodic follow up is suggested for clients with
psychosis, good transition to adult mental health service is crucial both
medically and functionally.
4.4 Mood disorders
Mood disorders were once thought to be nonexistent among children

and adolescents (Lock, 1997; Schroeder & Gordon, 2002). However, in the
mid-1970s, mood disorders with depressive symptoms such as Major
Depressive Disorder and Dysthymia were recognized as childhood disorders
and a decade later bipolar disorders were included (Fristad & Goldberg-Arnold,
2004). Currently, nearly 4-6% of individuals under age 18 are suffering from
various forms of mood disorders.
4.4.1 Depression in Adolescent
The prevalence of common mental disorders was 16.4%, a small but

representable population among the Hong Kong Chinese adolescents (Leung
et al. 2008). Depressive mood is commonly seen among local adolescents
(Centre for Health Protection, 2012). Its prevalence increases sharply with
age, especially during adolescence (Zgambo et el., 2012). Studies have been
done on adolescents in Hong Kong, showing that 50% of the participants
were suffering from depression (Sun, Hui, & Watkins, 2006). The Child Health
Survey 2005/2006 reported a prevalence of doctor-diagnosed depression for
children aged 11-14 is 0.2% (Department of Health, 2006). Surveys
conducted by Baptist Oi Kwan Social Service and the Institute of Education
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have interviewed 10,140 Form One to Form Six students in 22 schools
between October 2014 and April 2015. Results showed that a total of 51% of
them were inclining to depression at different levels, while 12.9% of students
were moderately depressed and 6.5% were severely depressed (Cheng,
2015).
Apart from the profound impact on physical function, depression was

also associated with increased risk of mortality, particularly through
committing suicide (Centre for Health Protection, 2012). A recent study
conducted by Cheng in 2015 stated that almost 24% of pupils had considered
committing suicide two weeks before the survey, with around 1.9% saying
they would really do so if they had a chance. A study revealed that up to 80%
of people who committed suicide had depressive symptoms (Krug, et al 2002).
People with major depressive episodes might need hospital admission for
close monitoring and treatment. In 2010, there were over 2600 cases of in-
patient discharges and deaths in public and private hospitals due to a
depressive episode or recurrent depressive disorder, 0.8% were aged 14 and
below and 9% were among people aged 15-24 (Hospital Authority,
Department of Health and Census and Statistics Department., 2010).
Children and adolescents who were suffering from mood disorder could
be very different from adults with the same disorder (Empfield & Bakalar, 2001;
Fristad & Goldberg-Arnold, 2004; Merrell, 2001). For instance, adults with a
depressive disorder have symptoms of feeling blues and fatigue, lose interest
in activities, insomnia, weight change, inability to concentrate, and suicidal
thoughts. However, children and adolescents could experience the same
things but they were more likely to be irritable than experience sadness and
somatic complaints (Merrell, 2001).
The consequences suffered by children and adolescents with mood

disorder were serious and could stunt their social, emotional, and academic
development. Those struggling with mood disorder often experience poor
social skills, difficulty in making decisions, inadequate coping skills, and might
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turn to drugs and alcohol (Naparsteck, 2002). Once they have developed a
form of depression, they might not perform well on their schoolwork.
There are options for the treatment of mood disorders in children and
adolescents. Medications are widely used for both the depressive disorders
and the bipolar disorders (Papolos & Papolos, 2000). Psychotherapy is often
used as well, not only helping the children or adolescents, but also supporting
the family. As part of the multidisciplinary team, OTs may jointly implement
these programs. Besides, OT often received referrals when the adolescents
found to have persistent dysfunctions in their education, social and other life
roles. Therapists will provide assessment and counselling in education/
vocational planning; specific life skills training and advice on accommodations
tailored to the cases’ needs.
4.4.2 Anxiety in Adolescent
According to Ryan and Warner (2012), anxiety was one of the most
common psychological disorders that children and adolescents could face.
Everyone experienced anxiety in their everyday life, mild or short periods of
anxiety could be released by resolving the cause of anxiety. However, high
levels of chronic anxiety could lead to depression. The Hong Kong
Polytechnic University and Christian Family Service Centre (2013) had jointly
conducted a large-scale study on the family life, physical and emotional health
of high school students. The study, spanning over three years since 2011,
showed that students had experienced mild (30.2%) to moderate (12%) levels
of anxiety in the two weeks prior to the survey while 5.7% students
experienced severe levels of anxiety in the same period of time (The Hong
Kong Polytechnic University, 2013).
It was suggested that up to 25% of young people experienced anxiety

at some stage during their formative years (Chavira, Stein, Bailey, & Stein;
Costello, Mustillo, Keeler, & Angold, as cited in Mychailyszyn et al., 2011; Neil
& Christensen, 2009). If the condition was left to be untreated, it would lead to
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a range of social and psychological problems such as loneliness, dysphoric
moods, underemployment, substance abuse, depression, and suicidal
ideation (Rudd, Joiner, & Rumsek, as cited in Mychailyszyn et al., 2011; Ryan
& Warner, 2012). The early onset of anxiety during these formative years was
also said to be a sign of serious adult psychopathologies, such as anxiety
disorder and major depression. Numerous child and adolescent anxiety
management programmes demonstrated efficacy in previous randomised
clinical trials, and were endorsed in the research literature as meeting the
standard for empirically supported treatments (Barrett, 1998; Barrett, Dadds,
& Rapee,1996; Kendall, 1994; Kendall et al., 1997; Silverman et al., 1999).
Amongst the aforementioned, cognitive behavioural therapy (CBT) happens to
be the most heavily supported approach to treat child and adolescent anxiety
(Ollendick & King, 1998).
4.5 School refusal
School refusal is one of the presented behaviors of school absentee.

Such behavior is illegitimate, and more specifically to child-motivated refusal
to attend school or difficulty attending classes or remaining in school for an
entire day.
Silverman and Kearney mentioned that school refusal behavior was a

child’s refusal to attend or stay in school which motivated by multiple desires,
i.e. (a) to avoid school-based stimuli that provoke negative affectivity (e.g.
anxiety, depression), (b) to escape aversive social or evaluative situations (e.g.
difficulty making friends or talking to others in class or in front of the class), (c)
to get attention from significant others (e.g. parents), and/or (d) to pursue
tangible reinforcers outside school (e.g. going to the mall) ( Kearney,
2007;Kearney & Albano, 2004; Kearney & Silverman, 1990, 1993, 1996).
Children presented with school refusal exhibited poor academic

achievement (Lamdin, 1996) and eventually missed the important school-
related developmental experiences ( Cha´vez, Belkin, Hornback, & Adams,
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1991). It resulted in poor social skills and low efficacy for coping with stressful
situations. Also, they were at risk of dropping out of school (Alexander,
Entwisle, & Kabbani, 2001; Rumberger, Ghatak, Poulos, Ritter, & Dornbusch,
1990).
Kearney (2001) reported that school refusal behaviors might affect 5-

28% of youth at one or more time, which could lead to serious short and long
term difficulties. A comprehensive community study was conducted by Eggar,
Costello & Angold (2003), it revealed the total prevalence rate of anxiety-
based school refusal and truancy to be 8.2% in youth. Meanwhile, Suveg and
his colleagues had showed the prevalence of anxiety-based difficulties in
attending school at 1–5%, but this remains controversial (Suveg et al., 2005).
Although there are a number of studies on the prevalence rate of

school refused, there was inadequate local statistical finding about the
prevalence of school refusal in Hong Kong.
Adolescents with school refusal behavior commonly possess different

levels of psychiatric conditions which precipitate their absenteeism or
extended absences.
There were 2 major studies investigated the comorbidity of psychiatric

conditions with school refusal behaviors in western countries. One study
represented a community sample and one represented a clinical sample. In a
community study, Egger et al. (2003) utilized the Child and Adolescent
Psychiatric Assessment to diagnose 165 youths with anxiety-based school
refusal and 517 youths with truancy or otherwise unexcused absences. The
most common diagnoses for youths with anxiety-based school refusal
included depression (13.9%), separation anxiety disorder (10.8%),
oppositional defiant disorder (5.6%) and conduct disorder (5.0%). In all, 24.5%
of this group received a diagnosis. Other than that, there is another diagnostic
study involving case reviews for 93 in-patients and 58 out-patients aged 10–
17 years old with school attendance difficulties. The most common specific
17
disorders among the two groups were major depression (31.8%), dysthymia
(25.2%), oppositional defiant disorder (23.8%), and separation anxiety
disorder (22.5%).
School refusal is a presenting problem which does not imply any

clinical diagnosis. However, the appearance of such problem might indicate
the risk for adolescents to suffer from mental health problems.
In local hospital settings, there were certain number of adolescent

clients who admitted to in-patient treatment with school refusal as chief
complaint; they are mostly new to mental health service and are found to have
certain clinical diagnoses, such as underlying depression and anxiety. Intense
medical treatment for mood stabilization and early functional training with
respective assessments are provided during the in-patient period. Meanwhile,
those adolescent clients who are already known to our service and presented
with school refusal would be seen and followed up in the day hospital setting
or out-patient setting in the usual practice.
In the management of adolescents who refused schooling, multi-

disciplinary approach is employed, including psychiatrists, clinical
psychologists, occupational therapists, Red Cross school teacher and social
workers.
4.6 Occupational Therapy in Adolescent Transition Programs in Hong

Kong
Compare to the western countries, Hong Kong adolescents in Mental

Health Service face similar challenges. Occupational therapists are therefore
involved in facilitating positive transition outcomes for these clients in terms of
self-care, work/education and leisure pursuits.
OT would collaborate with clients and their parents in reviewing their

daily schedule and time use for lifestyle re-design intervention, so as to
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establish a more adaptive lifestyle in the early phase. OT colleagues may
make use of the workshop based training to facilitate the clients on forming
meaningful daytime engagement as well as structured daytime routine. At the
same time, exploration and planning for work and study options in the future
would also be advocated through different psychological modalities, e.g.
coaching, cognitive-behavioral therapy solution focus therapy, problem solving
therapy, motivational interviewing If they prefer to work; further vocational
rehabilitation service would be provided, which includes vocational counselling,
vocational exploration/trials, community referral out for supported employment
and on-the-job training. These programs also often involve a platform for the
adolescents to train up their social skills with peers in social gathering.
Activities of daily living and independent living skills training will also be
provided where necessary.
After the completion of OT treatments, adolescents would have their

individualized pathways, which are listed below according to their own choices
and capabilities:
1. Returning to original school;

2. Changing to new school;
3. Participating in the community transitional programs, e.g. Youth College;
4. Participating in the community vocational training programs, e.g. SKY
program;
5. Participating in the supported employment program, e.g. Sunnyway;
6. Continuing training in day hospital.
5. Outcome measures suggested for adolescents transitional program
Service outcome is an important element in all treatment programs. In

adolescent transitional programs, the outcome measures commonly used can
be divided into two aspects: functional outcome and specific performance
outcome measured by standardized assessment tools.
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The functional outcomes commonly measured are:
1. Placement in educational/ training programs (original school/ new school/

community vocational training programs/ Employee Retraining Board (ERB)
training courses).
2. Job placement (open employment/ supported employment/ work trials).
3. Sustainability (able to stay in the same placement for 2-4 weeks)1.
1 The aim of the employment service among adolescents was to provide

job experiences, therefore, the sustainability rating of the employment
service would be shorter than the traditional adults (3 months).
Furthermore, according to the Employment of Young Persons (Industry)
Regulations of Labor Department of Hong Kong, adolescents aged from
15, but under 18 years old are allowed to work, but the working hours are
restricted within 7 am to 7 pm, the maximum working hours a day is 8
hours and the maximum period of continuous work is 5 hours followed by
and interval of not less than 30 minutes for meal or rest.
The specific performance outcomes can be separated into two

categories: the generic outcome measures and specific performance outcome
measures.
5.1 Generic Outcomes
This includes some well-being and self efficacy measures on the

adolescents after receiving treatment. The commonly used assessment tools
include:
1. WHO-5 Well-being index
The 5-item World Health Organization Well-Being Index (WHO-5) is

among the most widely used questionnaires assessing subjective
psychological well-being. The scale has adequate validity as an outcome
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measure in clinical trials and has been applied successfully across a wide
range of study fields (Topp CW, Østergaard SD, Søndergaard S, Bech P
2015). The Chinese version of WHO-5 well-being index was translated and
validated in 2007 and its Cronbach’s alpha coefficient was equal to 0.84.
2. Chinese Version of the Short Warwick-Edinburgh Mental Well-being

Scale (C-SWEMWBS)
In the original form, the WEMWBS is proved to be a reliable and valid

tool for assessing quality of life in normal adults. The C-SWEMWBS
showed high levels of internal consistency and reliability against accepted
criteria. The internal reliability coefficient (Cronbach's alpha) for C-
SWEMWBS is 0.89 which is consistent with that of English version. The
corrected item-total correlation is high with Spearman's rank correlation
coefficients ranging from 0.57 (item 6) to 0.75 (item 5). Good test-retest
reliability was observed (r = 0.677; p = 0.001). Principal components factor
analysis identified a single component (eigenvalues, 4.28; 61.1% variance),
similar to the English version. Scores of C-WEMWBS were positively
correlated with the scores of WHO5 (r = 0.49; p < 0.001), suggesting good
concurrent validity.
3. Chinese General Self efficacy Scale (CGSS)
The CGSS is generic in design. The content validity of items was

endorsed by a panel of 8 rehabilitation professionals with 75% to 100% of
agreement. The scale was tested on 78 individuals with schizophrenia and
found to have excellent internal consistency (0.92-0.93) and very good to
excellent test re-test reliability (0.75-0.94). Exploratory factor analysis
yielded a two-factor solution explaining 69.0% of variance which was
different from overseas studies which showed the scale to be
unidimensional. The scale was concluded to be reliable and valid to assess
self-efficacy of Chinese with schizophrenia.
21
5.2 Specific Performance Outcome Measures
5.2.1 Cognitive Assessment
1. The Hong Kong List Learning Test 2nd Edition
The Hong Kong List Learning Test 2nd Edition (HKLLT 2ndEd) is a
Chinese list-learning which was designed to provide an individually
administrated assessment of the processes and organizational strategies
involved in learning verbal information. The HKLLT consists of a randomly
presented word-list (Random Condition) and another word-list that is
presented in block, with words that are semantically related presented
together (Blocked Condition). It incorporates the Blocked Condition and
Random Condition hopes to increase the clinical sensitivity. Chan (2000)
applied the Blocked Condition to the schizophrenic patients are found that it
provided significant clinical information for evaluating the effectiveness of
the external organizational cues in memory intervention.
The HKLLT 2nd Ed. is developed and standardized on 394 male and
female participants aged from 6 to 95 years. The reliability, Cronbach’s
alpha = 0.90 and the discriminant validity, canonical correlation = 0.80,
correct classification of "grouped" cases = 92 % of the blocked condition
were highly superior to those of the random condition. Without using the
blocked condition in the assessment, however, the random condition of the
HKLLT could also be used alone and was still a satisfactory instrument with
reasonably high reliability (Cronbach's alpha = 0.73) and discriminant
validity (canonical correlation = 0.69, correct classification of “grouped"
cases = 78%).
22
2. MATRICSTM Consensus Cognitive Battery
MATRICSTM Consensus Cognitive Battery (MCCB) is a hybrid battery

comprising multiple independent tests. It can act as an outcome measure
for studies of cognitive remediation. It can also act as a cognitive reference
point for non-intervention studies of schizophrenia and other psychiatric
disorders. This battery measures seven main domains, including speed of
processing, attention/vigilance, working memory, verbal learning and
memory, visual learning and memory, reasoning and problem solving, and
social cognition.
4-week test-retest intra-class correlation coefficients was 0.71 for the

speed of processing domain score, 0.85 for the working memory domain
score and 0.90 for the overall composite score.
3. Wisconsin Card Sorting Test
The Wisconsin Card Sorting Test (WCST) is designed as a measure

of problem solving and decision making. Currently, it is used as a measure
of such executive functions as use of external cues to guide behavior, self
monitoring, and tendency to perseverate. It is frequently used as a
measure of hypothesis generation and ability to shift response (Goldstein &
Green, 1995). Although the WCST was originally designed for use with
adults, the most recent manual for the WCST lists norms for children from 6
years 6 months of age through adulthood (Chelune & Baer, 1986).
The WCST consists of four stimulus cards that vary along three
dimensions. They vary in number, color and shape. Participants need to
match the given 128 cards that vary along the three dimensions with one of
the four stimulus cards. Participants need to derive a strategy
himself/herself from the feedback. Once 10 consecutive cards are correctly
categorized, the sorting principle changes without notice. Participants need
to derive a new strategy then. This procedure continues until all 128 cards
23
are being categorized. In addition to yielding total error scores, this test
yields separate measurements for perseverative and non-perseverative
errors and for the number of sorting categories achieved.
WCST-64 is one of the short version of WCST. The spearman

correlation (r) for the Child and Adolescent Clinical Samples of the total
errors and individual sub-tests ranged from 0.514 to 0.895 (p=0.000)
except Failure to Maintain Set item which is not significantly correlated.
4. Children Color Trails Test
The Children Color Trails Test (CCTT) 1 and 2 measure processing

speed and mental flexibility. In both tests (CCTT1 and CCTT2), the
participants use a pencil to connect circled numbers from one to fifteen in
ascending order. In CCTT2, the connected numbers required to alternate
with colors (pink and yellow). The variables measured include completion
time in seconds, errors, prompts, and near-miss scores. Llorente (2009)
states that the completion time test-retest reliability in the moderate range,
which may be considered modest (r(tt) =.46-.68) in the sample of children
with ADHD. Interference reliability coefficients were greater and in the
moderate-high range (r(tt) =.75-.78).
5.2.2 Vocational Exploration and Training Assessments
1. LAM Assessment of Employment Readiness
Lam Assessment of Stage of Employment Readiness (LASER) is used

for evaluation of work readiness. It has been found to be a valid predictor
for workers’ readiness to work. The reliability coefficients (intra-class
correlation, ICC) on the item scores of the 14 items ranged from 0.55 to
0.79. There are three items: 7, 10 and 12 representing the pre-
contemplation stage, which has ICC values lower than 0.60, indicating that
these items have fair test-retest reliability.
24
2. Work adjustment Inventory: job related temperaments
The Work Adjustment Inventory (WAI) measures 6 work-related

temperament traits: Activity, Empathy, Sociability, Assertiveness,
Adaptability and Emotionality. It is designed for use with individuals aged
12 through 22 and can be administered to individuals or groups in about 20
minutes. Test items are written at the 3rd grade reading level and the
examiner may read the items aloud.
All reliability coefficients are significant at the 0.01 level and ranged
from 0.72-0.89, these values are of sufficient magnitude to allow
confidence in the test scores’ stability over time. Cronbach’s coefficient
alpha values of all scales of the WAI are significant beyond the 0.05 level of
confidence, ranging from >=0.7->=0.90. The inventory also demonstrated
good content validity, criterion-related validity and construct validity.
Nevertheless, there is no validated Chinese version available for the

Hong Kong population.
5.2.3 Social Skills Training Assessments
1. Chinese Social Problem Solving Inventory-Revised
The theory-based measurement of social problem solving processes

has two current versions: (a) a comprehensive 52-item version, which
consists of five scales (NPO—negative problem orientation, PPO—positive
problem orientation, RPS—rational problem solving, ICS—
impulsivity/carelessness style, AS—avoidance style), four subscales of the
RPS scale, and a total global score; and (b) a 25-item short form version,
which consists of the same five scales identified above and a total global
score.
25
The Chinese version of the scale (C-SPSI-R) including the sub-scales
has been found internally consistent and temporally stable over time. The
C-SPSI-R subscales are found to be internally consistent. It also has good
test-retest reliability with α ranging from 0.65 to 0.80 (α = 0.81 for AS, 0.73
for NPO, 0.69 for RPS, 0.65 for ICS, and 0.68 for PPO). The correlations
among the five subscales are largely consistent with expectation. There
were significant positive correlations (r = 0.47) between the positive
subscales (PPO and RPS), and among the negative subscales (r among
NPO, ICS, and AS ranges from 0.52 to 0.71). There are significant negative
correlations between the negative and the positive subscales (r ranges
from -0.08 to -0.19).
2. Chinese Social Responsiveness Scale
The Chinese Social Responsiveness Scale (C-SRS) contains 65 items

to assess the severity of autism spectrum symptoms, which occur in natural
social settings. The assessment is completed by parents or teachers in 15
to 20 minutes. The C-SRS draws a clear picture of a child's social
impairments, assessing social awareness, social information processing,
capacity for reciprocal social communication, social anxiety/avoidance, and
autistic preoccupations and traits. It is appropriate for use with children
from 4 to 18 years of age.
Exploratory factor analysis revealed a 4-factor structure. This was

validated by confirmatory factor analysis with an adequate fit (root mean
square error of approximation 0.031, comparative fit index 0.983, adjusts
goodness of fit index 0.910, standardized root mean square residual 0.050)
after excluding five items with low correlation coefficients. The 4-week test–
retest reliability (intraclass correlations 0.751–0.852), internal consistency
(Cronbach's alpha 0.944–0.947), and convergent validity with the Chinese
SCQ (Pearson correlations 0.609–0.865) demonstrates well-accepted
psychometric performance.
26
3. Social Skills Improvement System-Rating Scales
The Social Skills Improvement System-Rating Scales (SSIS-RS) are

scales to replace Social Skills Rating System. The rating scale assesses
individuals and small groups in terms of social skills, problem behaviors,
and academic competence. Teacher, parent and student forms help
provide a comprehensive picture across school, home, and community
settings. The administration would take 15-25 min. Chinese version of
SSIS-RS (SSIS-RS-C) is validated in Hong Kong population and is
appropriate for use with children aged from 5 to 18.
The Cronbach’s alpha for the 12 SSIS-RS-C subscales varied from

0.71 to 0.86, which indicating moderate to good internal consistency. The
internal consistency for the scale domains of the SSIS-RS-C version was
very good, as reflected by the Cronbach’s alphas of 0.95 and 0.94
respectively. The scores for the Hong Kong sample (n = 567) derived from
the use of the SSIS-RS-C were compared to the normative sample scores
from the American version of the SSIS-RS. It was also found that there
were statistically significant differences on five out of the seven SSIS-RS-C
Social Skill subscales for children aged 5–12 years and on four out of the
seven SSIS-RS-C Social Skills subscales for children aged 13–18 years.
Furthermore, there were statistically significant differences between the
American and Hong Kong samples on all of the SSIR-RS-C Problem
Behavior Scale scores.
27
Summary of outcome measurements
Chinese Version Validation Age range

Generic Outcomes
1. The Short Warwick-Edinburgh Mental Well-being Scale Yes Yes (HK) >= 13 y.o.
(SWEMWBS)
2. WHO-5 well-being index Yes Yes (HK) >= 13 y.o.
3. Chinese General Self –efficacy Scale Yes Yes (HK) 15-67 y.o.
Specific Performance Outcomes Measures
1. Cognitive assessments
1.1. The Hong Kong List Learning Test 2nd Edition (HKLLT) Yes Yes (HK) 6-95 y.o.
1.2. MATRICSTM Consensus Cognitive Battery (MCCB) Yes Yes (Taiwan, China) 20-59 y.o.
1.3. Wisconsin Card Sorting Test No No 7-89 y.o.
1.4. Children's Color Trails Test No No 8-16 y.o.
2. Vocational exploration and training assessment
2.1. LAM Assessment of Employment Readiness Yes Yes (HK) 20-58 y.o.
2.2. Work Adjustment Inventory Yes No 12-22 y.o.
3. Social skills training assessment
3.1. Social Problem Solving Inventory-Revised (CSPSI-R) Yes Yes (HK) >= 13 y.o.
3.2. Social Responsiveness Scale (SRS) Yes Yes (Taiwan) 4-18 y.o.
3.3. Social Skills Improvement System-Rating Scales (SSIS) Yes Yes (HK) 5-18 y.o.
28
6. Transitional Training Program in Adolescent Psychiatry
In Hong Kong, service for adolescents with mental health problems is

provided in a multi-disciplinary team approach, included psychiatrists,
psychiatric nurses, clinical psychologists, medical social workers and
occupational therapists. Adolescents in need of transitional care would be
referred by psychiatrist to OT for assessment and intervention. OT would
work with the adolescents, care takers, clinical team members and relevant
stakeholders, such as teachers or school social workers to develop a care
plan for adolescents.
OT offers a unique insight in transition service by providing occupation-

based evaluation and intervention. It is believed that action through
occupation integrates feeling, thinking and doing, which provide a sense of
coherence in an adolescent’s life at this time of transition. Action through
occupation also facilitates change, personal development, and wellbeing,
which makes transition easier.
Training adolescents requires specific counselling and coaching skills.

The therapist’s key objective is to increase the adolescents’ self-knowledge
and understanding, which ultimately facilitates development of role identities.
The involvement of family; the consideration of using group dynamic versus
individual treatment; daily living skills training and vocational/educational
transition exploration are the key issues in treating adolescents.
In providing treatment programs for adolescents who have been idling

at home for a period of time, engagement is one of the key issues. The
therapists may experience and go through the following stages:
1. Pre-engagement Stage
2. Engagement Stage
3. Exit Stage
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6.1 Pre-engagement stage
Pre-engagement stage is the stage before the formal appointment with

client was made. It is especially important for adolescent clients because
treatment initiation and engagement are recognized as important benchmarks
on the path to recovery. Unlike adult, who usually seeks service on their own
accord, adolescents are commonly brought to services by their parents.
Parents’ attitude and their perception of problems play important roles in
initiating service for the adolescents in need. On one hand, problems are
more likely to manifest internally, such as anxiety and depression are often
overlooked by parents or teachers. On the other hand, adolescents are more
developmentally independent, beginning to detach from parents and showing
deviance towards parents’ control, they want to get autonomous and
challenging from parents’ control. An agreement for entry into mental health
service would be difficult because it has traditionally been stigmatized by the
public. Treatment initiation by adolescents with mental health issues is a
major barrier for mental health providers.
Empirical study conducted by Lee, Garnick & O'Brien (2012) showed

that treatment process, such as shortening the time for initiation, would
increase the likelihood of clients engaging in treatment.
6.1.1 In reach program
As adolescents usually do not perceive their need for therapeutic

treatment and do not initiate therapy contact. The essential components of an
effective treatment are the quality of the interaction and the personal bonding
between adolescents and therapists. In order to build up a successful
engagement for adolescents from in-patient status to out-patient or day-
patient status, therapists would take up a more proactive role to engage
adolescents. Informal intake would be done in pre-discharge phase. It
provides an opportunity for future case therapist to contact with the
adolescents. It also provides the channel for the adolescents to know more
30
about the day hospital environment as well as the out-patient setting.
Therapists would also join in the in-patient case conference for understanding
the updated information and treatment plan of each adolescent. The initial
contact with adolescents in pre-discharge phase would help increase the
connection and create bonding between adolescent and therapist. A good first
impression e.g. therapist presents a positive and hopeful attitude, would help
the adolescents understand therapist would be a source of support, and
therapist was able to validate the adolescents’ feelings, extend non-
judgmental acceptance, so that to increase the possibility for adolescents to
continue receiving treatment in day patient/ out- patient setting.
Some hospitals have introduced an in-reach program for adolescents in

in-patient treatment for building up connection in pre-discharge stage and
preparing for the continuity care for adolescents from in-patient treatment to
day patient or out-patient treatment.
6.2 Engagement stage
Mental health workers who work with adolescents encounter a major

challenge of engaging adolescents with our service. Engagement indicated
the degree to which adolescents actively participate in treatment, not only in
terms of attendance, but also satisfaction and perceptions of personal
progress (Joe, Simpson, & Broome, 1999). Pre-mature service termination or
drop-out from service has significant impact on treatment outcome, leading to
comparatively poorer long term clinical and functional outcome and service
dissatisfaction.
Adolescents tend not to seek professional help for a variety of reasons

as below: (1) they may not believe that they need help; (2) they often are not
aware of the range of services available; (3) they may be concerned about the
stigma of obtaining mental health services or be hesitant to seek assistance
from adult. Therefore adolescents are far more likely to seek assistance for
problems with employment, relationships, and family than they are for mental
31
health or emotional issues. OT service, including vocational assessment,
cognitive assessment, career planning or study planning might be in a better
position to encourage engagement of adolescent with our service.
6.2.1 Study/Career planning program
Adolescence is a stage of rapid growth where people undergo

important changes in physical, social, cognitive, moral and psychological
aspects. It is also a stage of transformation where adolescence transiting into
adulthood. The process of choosing an occupation is difficult, but important
for most adolescents. It is a process where individual discovers his or her
interests, values, and abilities that relate to specific occupations. OT facilitates
adolescents’ study/career development process by increasing their capacity
and willingness to plan for the future. The essential components of
study/career planning program included self-awareness, self-efficacy,
information of the support services and agencies available in the community,
developing personalized career plan as well as network building with services
and agencies in the community. The study/career planning program might be
conducted in individual or group basis.
OT will use questionnaires or aptitude tests such as MBTI, strength test,

GOE, Pro-3000 and tests that are available online, such as those in
www.HKFYG.org.hk, www.authentichappiness.sas.upenn.edu., www.self-
directed-search.com. They provide basic information on the individual’s
personal attributes. OT will also help adolescents to reflect deeper upon their
character strength and characteristic through purposeful activities, such as
adventure activities, group games. The book named ‘職業字典’ provides
detailed Information of the job description. It enhances adolescents to
develop a basic understanding of the job requirement and duties. OTs would
also facilitate the process for adolescents to explore and match job that are
more likely to match his/her temperament.
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6.2.2 Vocational exploration
Vocational exploration is a continual process that requires adolescents

to gather information about careers. This program is specifically designed to
facilitate adolescents who begin to plan their future career as well as their
career pathway; to gain better idea of where they are heading to by engaging
them in different vocational assessments and further career research. Other
than that, adolescents would be able to try out different work-related tasks or
activities, helping them to determine how their interests match their abilities.
Hence, both their skills and strengths would be built and enhanced.
6.2.3 Vocational assessment
In Hong Kong, OT had an established role in offering a range of

vocational assessments and training services to people with mental health
problems. It is because OT has an understanding of the relationship between
the individual’s medical condition, functional abilities, psychosocial status and
work demands. Assessments are applied under a holistic human
development and function.
For adolescents with mental illness, it is wise to balance standardized,

formal evaluations with clinical observations, work simulations, and collateral
information gained from parents or caregivers, or other members of the team.
OT employs different vocational assessments that addressed the interest,
aptitude, work behaviors and skills of individuals. OT would also evaluate the
work place issues, such as working environment, work task demand, degree
of support being offered in work place. Hence the readiness of the
adolescents entering the workplace is determined.
It is expected that adolescents are able to understand more about

themselves, i.e. career decision making, interest, skills, values, meaning of
work, own personal traits and characteristics as well as their own potential
through the discussion of the assessment results.
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6.2.4 Pre-requisite work skills training
Adolescents are supposed to understand more about their own

condition after the vocational assessment. OTs would accompany them while
they learn about careers in terms of types of jobs, educational requirements
and job functions. This encourages and facilitates them to understand which
potential careers would fit their interests and goals. Through this process,
training in (1) crucial life skills, i.e. scheduling, decision making,
communication skills, financial management, (2) generic work skills, e.g. job
hunting, making resume, interviewing skills, work related social skills,
computer skills and (3) specific simulated job tasks, e.g. clerical work are
introduced and encouraged, so that they are able to build up work habits and
pre–requisite work skills.
6.2.5 Career counselling
Apart from these, individual coaching sessions would be provided to

relate adolescents’ interests and characteristics, potential careers and their
abilities/skills. OTs would collaborate with them to evaluate their personal
choices. Such collaboration would be a back and forth relationship according
to their choices in careers.
6.2.6 Work place experience
Adolescents are not only benefited from workshop based training

mentioned previously but also benefited from real life work experiences with
support. Different mode of work place experience would be discussed below:
1. Work trials
Adolescents would be arranged to work in real work setting for a

designated period of time, usually a short period of time, e.g. 1-2 weeks.
34
They would receive on-the-job training during the work trial period from
staff in their respective company/workplace.
During the work trial, adolescents are expected to gain more practical
work experience with the increase in awareness of responsibilities,
competencies and duties required in the real life work place. Their skills
would be re-built and further enhanced with competencies in line with the
needs of current labour market, at the same time, their confidence in the
workplace would be fostered, and as well as their self-esteem.
2. Work placement
Individual placement and support (IPS) or supported employment

commonly seen in Hong Kong showed positive effect for the transition
service. The IPS model possessed higher achievement for competitive
employment by strengthening work readiness, providing skill training and
job seeking assistance.
In Hong Kong, some occupational therapy units provide supported

employment service for clients with mental health problem. OT provide
support service, including employment-related skill training, on-the-job
coaching, vocational counselling and support to clients. They would actively
liaise with employer, to provide on-going support, and bridge the
communication gap between employee and employer.
6.2.7 Community vocational programs
The transition from hospital setting into community is also advocated in

the recent few years. There are a number of vocational support program
provided for adolescent with specific mental health problems.
Selective placement program offered by Labour Department provides

vocational support in terms of job counselling and job placement to individual
35
with disabilities. The Vocational Training Centre offered a range of programs
such as skilled centres that provides intensive vocational training followed by
job placement to people with disabilities. The Social Welfare Department
collaborated with certain NGO to provide the Sunnyway on the Job Training
Program for youth with disabilities.
There are a certain number of NGOs which provide and organize

specific project-based vocational programs to facilitate adolescents who are in
need after discharging from hospital, for example, STAR project for
adolescent with disabilities by Hong Kong PHAB Association, Sunnyway
program for adolescent with disabilities held by a number of NGOs and SWD,
Project Bridge for SLD by the HK Federation of Youth Group, My Sky program
for ASD by Yang, 職萌支援計劃 for adolescent with disabilities by Asbury
Methodist Social Service, Star Project 星亮計劃 for ASD by Heep Hong
Society, A Plus and 吾懂人情, 真色珍我 for ASD by SAHK.
6.2.8 Cognitive assessment and remediation
There is evidence (Nuechterlein et al, 2014) which supported that

cognitive deficits are the enduring core features of first episode psychosis,
and they are predictors of patients’ everyday functioning. Individuals with early
onset psychosis exhibit increased neuroanatomic abnormality compared with
adult-onset patients. Studies (Bachman et al., 2012) suggest that individuals
with adolescent onset psychosis suffer from severe disruption in the neural
developmental maturation processes, and their abnormal neurodevelopment
accounts for the divergent developmental trajectory that could predict their
world functioning later in life. Cognitive assessments not only provide practical
information on the functioning of adolescents with mental health issues, they
also form a solid basis for adolescents to engage in program that can address
their core concern.
In the local OT practice, common cognitive assessments adopted

included MCCB, HKLLT, Trail Making Test, WCST, CCTT etc.
36
Cognitive remediation
OT also provide cognitive remediation according to the need of

adolescents. Scientific evidence supported the effect for cognitive
remediation to adolescents with mental health problems. Improvement in
executive function, reasoning abilities, social cognition, working memory,
verbal memory and cognitive flexibilities were reported (Urben, Pihet, Jaugey,
Halfon, & Holzer, 2012; Grynszpan et al., 2011 & Wykes et al., 2007)
There are 4 components of the cognitive remediation.
1. Psychoeducation
The psychoeducational talk will cover the areas of basic concept of

brain development, component of cognitive functioning, cognitive
impairment resulted from different mental health problems such as ADHD
or psychosis, cognitive remediation strategies such as attention training,
memory strategies and executive functions. It will also introduce different
cognitive learning strategies such as verbalization, information reduction,
breaking and simplifying the task into smaller steps, providing written
prompts, chunking, self-monitoring, mnemonic strategies, categorization,
organization, and planning.
2. Computer-assisted cognitive program
Computerized program is well accepted and documented to be an

effective media for adolescents. There are commonly used computer-
assisted cognitive program included but not limited to Captain’s Log,
Cogniplus and RehabCom.
The essential component of the computer assisted cognitive

remediation was drilled and practice. Participants are required to
participate in a total of 16-20 session of training. While each training
37
session should be lasted for 30 minutes or more with frequency of 2-3
sessions per week.
3. Bridging program
The bridging program facilitate the learnt cognitive to be generalized in

the real life situation. The client will be asked to apply the cognitive training
strategies into daily life situations such as household management,
organized leisure activities or social activities, work environment etc.
Format of bridging program can be either individual or group based
depends on the nature of the tasks. Activities such as tea party, social
games, board games and simulated work skill workshop training will be
arranged.
4. Home program
The client will be asked to conduct a home program target to

implement the learnt cognitive strategies. Client will discuss with OT to
identify a home program that is relevant to him/her. Client’s performance
will be reflected and possible difficulties will be identified. Core cognitive
components of the tasks will be evaluated. They will then identify cognitive
strategies to manage the task. The essential components are the set
program is initiated by client which is meaningful to him/her.
Life preparation and Life Role Enhancement Programs
Adolescents are undergoing a life-changing phrase where they transit

from childhood to adulthood. Life skill preparation is a crucial element to
facilitate a smooth transition.
6.2.9 Occupational Lifestyle Redesign (OLSR) Program
In most healthy people, their occupational lifestyle supports both
38
physical and mental aspects, fosters personal growth and development, as
well as leads a generally happy and purposeful life. Lifestyle characteristics,
such as activity engagement, nutritional habits, and coping behaviors have
been shown to be related to life expectancy, well-being, and health.
Adolescents with mental health problems experience difficulties in

maintaining their customized life style, resuming their life role in leisure, social,
work or study and home making due to various reasons, e.g. illness,
adjustment issues or transitional problems. They often lack interest in
activities and lack psychological strength to meet challenges in everyday life.
This might cause the dissatisfaction in life and deterioration in overall physical
and mental health. This often manifests in the form of imbalance activities
content in daily life, such as indulging in smart phone games or surfing the
Internet. A vicious cycle of imbalance and dissatisfying lifestyle results from
the occupational lifestyle dysfunctions.
Occupational lifestyle redesign (OLSR) program is designed to

enhance active patterns of positive social engagement and increase their
positive social engagement patterns and quality of life. Preliminary data on
efficacy of the OLSR program suggested that the wellbeing and functional
performance of adolescent received the program had been improved
significantly.
In Hong Kong, there are several manualized life style redesign

programs such as OLSR program on career planning for adolescent with
chronic illness-“青少年生活重整及職能培訓證書”by PMH and QEH, OLSR-“樂
動方程適” by KCH, Loving Living Program and 5-ways to Wellbeing Program.
6.2.10 Practical living skills
Practical living skill is crucial for an adolescent to become a successful

and independent adult. It prepares the adolescents to be more independent
and confident to navigate in the real world. By mastering the efficient practical
39
living skill, they would be able to live on their own and enjoy a happy and
successful life afterwards (Mannix D, 2009).
The practical life skills program aims to focus on identifying

adolescents’ weakness in life skill activity. The program provides opportunity
for adolescents to learn, develop and strengthen their ability to perform life
skills so they can develop successful independent lives in adulthood. They
would learn about the importance of practical life skill in their daily lives and
became more efficient to manage their own life in the future. Through the
program, adolescents could increase their awareness of their own strength
and their competencies in performing various practical life skills. Adolescents
would understand their usual way to perform the life skill activities and are
provided with instructions to improve it.
The suggested practical life skills included in this program are the:
1. Skill of information acquisition
 Identifying Information need to know
 Different ways to access information
2. Financial management skill
 Making a budget
 Making payments
 Unit pricing
 Making a check
 Maintaining a saving account
 Applying credit card or loan
3. Transportation skill
 Local Transportation
 Planning a trip
 Estimating cost
 Using a timetable
 Reading a map
4. Home management skill
 Home Keeping
40
 Home Repairing
 Caring of clothing
 Preparing a meal
 Shopping
5. problem solving skill
 Handling problematic situation
 Making Decision
 Recourses management
 Goal setting
 Risk management
6.2.11 College Preparation and transition program
Adolescent with mental health problems have difficulties in transition to

new life role. The program aims to provide support and enhance their
preparation and better the transition to their college life. Specifically, the
symptoms of ASD / ADHD might affect their executive function and social
communication while transitioning to college. The transition program is
designed to enhance social skills for better communication with peers and
other significant figures in college. It also aims to develop their executive
function (e.g. time management, goal setting and stress management, etc.) in
order to facilitate their success in college. The contents of the program are
mainly focused on organization and social communication in academic and
personal life.
6.2.12 Interpersonal Skills or Social Skills Training Program
Occupational therapy provides social skills training to adolescents in

order to enhance their social skills upon interaction with peers, family,
colleagues etc.
Social skills training which focuses on social behavior is beneficial to

adolescents. Social skill training program usually includes group discussions,
41
role plays, and homework assignments. Some social skills training also
includes parent education in order to provide home program for better
generalization. Social skill training teaches adolescents the skills they need for
successful social interactions. The Program for the Education and Enrichment
of Relational Skills (PEERS®) originally developed at UCLA, is a manualized
intervention for youth with social challenges. It has a strong evidence for the
use with adolescents and young adults with ASD, but is also appropriate for
preschoolers, adolescents, and young adults with ADHD, anxiety, depression,
and other socioemotional problems.
Social Cognition and Interactive Training (SCIT) is a group training

program (Roberts et al., 2016). It originally targets people with Schizophrenia,
emphasizing several key social cognitive domains that appear to interact in
hindering effective social behaviors. With modification, clinical application to
adolescent with ADHD and ASD, may also be feasible. The training focuses
on active social cognitive processes. It requires participants to understand,
recognize, monitor, and implement their own social cognitive processes. The
training highly emphasizes on cognitive processes than cognitive content,
targets distorted interpretive processes that may generate and maintain social
difficulties.
Work-related social skills training is also beneficial to adolescents

undergoing transitioning from the role of a student to a worker. The training
was aimed to improve adolescents’ social competence to secure a job. Social
skills training could be used to facilitate job search and job tenure for
participants. The application of social skills training should be within the
vocational context. Researchers (Tsang 2003; Dauwalder and Hoffmann
1992; Stuve et al. 1991; Wallace et al.1999) suggest that efforts should be
geared towards the development of workplace social skills training and apply
parallelly with the latest cognitive behavioral therapy approaches in vocational
rehabilitation.
42
6.3 Exit stage
Treatment goal of client will be reviewed continually. Client will be exit

from OT service when he or she had achieved his/her personal goals. They
will resume the previous study or worker role, secure a new study or work
placement or be transferred to other service providers before they terminated
from service. Some of the clients will be followed up by OT to provide booster
sessions or continue support to facilitate the client on his or her transition.
For cases require continuous care, a good transition can encourage

treatment compliance from child and adolescent mental health service to adult
mental health services.
43
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1

Brian Fung, OTII, CPH

Cherie Wong, OTI, UCH

Fiona Wan, OTI, QMH

Linda Yau, OTI, UCH

Magdalene Poon, SOT, KCH

Peggy Nip, OTI, AHNH

Rita Ng, OTI, KCH (Convenor)

Sharon Leung, OTI, AHNH

Shiren Wong, OTI, CPH

Wallis Chan, OTI, CPH

Adolescence is a transitional period between childhood and adulthood.

Transition service has been defined in the Individuals with Disabilities

Therefore, it is the process to enhance independence and autonomy by

2. Characteristics of good transition

Adolescents with psychiatric illnesses like Autism Spectrum Disorder

Oswald (2013) identified several factors that contributed to successful

Oswald also identified some determinants associated with a successful

To conclude, there are five factors associated with favorable

3. OT roles in transitional care

Occupational therapists (OT) have expertise in technology, task and

According to American Occupational Therapy Association (2008), OT

1) Prepare the student, family and community agency representatives for

In 2016, the common diagnoses for cases aged from 12 to 18 receiving

4.1 Autism Spectrum Disorder (ASD)

According to University Grants Committee, 2% of students with

The employment rates for individuals with ASD, regardless of

Career awareness, community experience, parental involvement, study

Wehman and Schall (2014) stated some best practices particularly

Besides the Hospital Authority service, the non-government

4.2 Attention Deficit/Hyperkinetic Disorder (ADHD)

The prevalence rates of ADHD in children and adolescents were high

ADHD is seen as a deficit in behavioural inhibition, sustained attention

Problems that an ADHD adolescent might encounter in workplace

Psychosis affected up to 1% of the population and the annual incidence

The first psychosis episode typically occurs during a critical

Social and functional outcomes in psychosis were frequently reported

A 5 years follow up study reported that only 25.5% of people with

For adolescent onset psychotic cases, there is evidence that the

In Hong Kong, a territory wide, phase specific service program for

4.4 Mood disorders

Mood disorders were once thought to be nonexistent among children

4.4.1 Depression in Adolescent

The prevalence of common mental disorders was 16.4%, a small but

Apart from the profound impact on physical function, depression was

The consequences suffered by children and adolescents with mood

4.4.2 Anxiety in Adolescent

It was suggested that up to 25% of young people experienced anxiety

4.5 School refusal

School refusal is one of the presented behaviors of school absentee.

Silverman and Kearney mentioned that school refusal behavior was a

Children presented with school refusal exhibited poor academic

Kearney (2001) reported that school refusal behaviors might affect 5-

Although there are a number of studies on the prevalence rate of

Adolescents with school refusal behavior commonly possess different

There were 2 major studies investigated the comorbidity of psychiatric

School refusal is a presenting problem which does not imply any

In local hospital settings, there were certain number of adolescent