Implementation of a youth‐adult partnership model in youth mental health systems research: Challenges and successes

Abstract Background By integrating Youth–Adult Partnerships (Y‐APs) in organizational decision making and programming in health‐care settings, youth can be engaged in decisions that affect them in a way that draws on their unique skills and expertise. Despite challenges, Y‐APs can have many benefits for youth and adults alike, as well as for the programmes and initiatives that they undertake together. Objective This article describes the development, implementation and success of a Y‐AP initiative at the McCain Centre at the Centre for Addiction and Mental Health, a large urban hospital. Method The McCain Y‐AP implementation model was developed based on the existing literature, guided by the team's progressive experience. The development and implementation procedure is described, with indicators of the model's success and recommendations for organizations interested integrating youth engagement. Results The McCain Y‐AP has integrated youth into a wide range of mental health and substance use‐related initiatives, including research projects, conferences and educational presentations. The model of youth engagement is flexible to include varying degrees of involvement, allowing youth to contribute in ways that fit their availability, interest and skills. Youth satisfaction has been strong and both the youth and adult partners have learned from the experience. Discussion Through the McCain Y‐AP initiative, youth engagement has helped advance numerous initiatives in a variety of ways. Flexible engagement, multifaceted mentorship, reciprocal learning and authentic decision making have led to a successful partnership that has provided opportunities for growth for all those involved. Health‐care organizations interested in engaging youth can learn from the McCain Y‐AP experience to guide their engagement initiatives and maximize success.

community citizenship. 3 Moreover, youth gain awareness, new skill sets and control over their own health leading to significantly better health outcomes. 3 Y-APs can manifest in several contexts, including civic engagement, 4 community programmes, 5,6 education 7,8 and research. 9 There have been recent efforts to introduce Y-APs into the mental health-care system, 10

| Youth-adult partnerships
Creating Y-APs can be challenging, especially in settings where power imbalances are expected, such as in a school environment, or research teams where youth are often seen as consumers rather than stakeholders. 13,14 Accordingly, implementing successful Y-APs requires flexibility, mentorship, authentic decision making and reciprocal learning. 2,8,11 Flexibility involves malleable roles that allow both youth and adults to showcase their skills and talents. In addition, flexibility regarding deadlines, milestones and overall goals is critical. 11 Moreover, to achieve their goals, Y-APs must not replicate the power imbalance seen in parent-child or student-teacher relationships 15 but should create safe, welcoming environments where all parties' opinions and contributions are respected and valued. 16 To recognize that each person has a unique skill set, all partners must be willing to abandon preconceived notions of the way partnerships or relationships between youth and adults work. Empowerment is not solely the responsibility of the adults or the youth, but is rather a shared duty involving co-learning 16 , defined as reciprocal learning.
In Y-APs, youth are decision makers rather than consumers or consultants. 8 That is, youth have responsibilities and are trusted to make decisions that directly influence team projects and outcomes in their own lives. Wong discusses possible degrees of participation using Hart's model of youth engagement. 16 The model is an eightrung ladder depicting progression from poor to excellent engagement typologies. At the non-participation level, youth are involved only to have youth engagement appear important, but are not provided with an understanding of the issues nor decision-making opportunities.
Progressing up the ladder, youth engagement becomes both more fulsome and authentic. Youth transition from understanding projects and having their views respected at the lowest level of participation to having complete liberty over projects, including using their own ideas and inviting adults to join them in decision making at the highest level.
The nature of the relationship in Y-APs is one of reciprocal learning: all parties are both teachers and learners, relying on individual strengths, 9 as opposed to traditional structures of age and education determining power. For example, in research, adults may be experts in research methods, while youth may be experts about their school environment. Together, diverse expertise works in cohesion to create a successful, well-grounded research project.

| Flexibility
Individuals with mental illness may have different working styles and needs than the general working public. 17  and talents they wish to develop through NYAC involvement. This information is used to guide committee processes and match members with relevant, personally meaningful opportunities.

| Mentorship
In line with the literature, 15

| Authentic decision making
Authentic decision making, an essential component of Y-APs, must be developed intentionally to ensure full implementation and maintenance. Y-APs can slide into "tokenism" "unless genuine opportunities exist for youth to participate in decision-making processes" (p. 222). 18 In the McCain Y-AP, authentic youth engagement is clearly demonstrated through active participation in research, proposal writing, presentation development and facilitation and by being recognized as equal team members.
Authentic decision-making opportunities were built into NYAC including on-going open dialogue with members about NYAC structure and operations which has resulted in recommendations that have been implemented. For example, in response to member concerns that NYAC's webpage was overwhelming and cluttered, YEFs implemented several solutions, including using another platform, categorizing topics and creating a page strictly for member opportunities, changes that were well received by members. In addition, NYAC members have opportunities to co-create their own projects, with YEFs providing guidance and structure but with ultimate decision making by NYAC youth.
NYAC's first antistigma campaign, #selfree, provides a strong example of this approach.  Learning from the challenges previously reported, 11 flexibility was integrated into the model, enhancing its success. A multi-level mentorship structure, in which adults mentored YEFs, adults learned from YEFs and YEFs mentored a broader network of youth, created a welcoming environment where a diversity of opinions, contributions and strengths are respected and valued. 9, 16 The result has been skill building that prepares youth to become engaged adults, with potential positive long-term impacts on their health outcomes, 3,12 while helping guide the adult allies in the development of youth-friendly initiatives.

| Implications/Recommendations
This process has been a considerable learning experience for the McCain Y-AP team and the organization as whole. Based on this experience, we propose several recommendations for health-care organizations wishing to implement Y-AP initiatives: • Develop partnerships with young people early in the planning process.
• Be proactive about planning and developing guidelines for youth engagement, recognizing potential organizational barriers and/or policies that may need to be revised.
• Recognize the need for training about youth-adult partnership and co-creation.
• Establish a method of recruitment that speaks to the diversity of the individuals being sought.
• Develop an understanding of the needs of the organization and/or projects to guide engagement strategies.
Y-AP planners should remember that engagement and partnership do not have to be perfect. The key is to stay true to core values and strategies in finding creative ways to reach out to youth. As illustrated by the McCain Model of Youth Engagement, there are many ways to engage youth appropriately and meaningfully, even without extensive resources.

| Limitations
This paper describes the McCain experience, which may not generalize to environments where broad online contributions and facilitation are not feasible. NYAC's membership may have been bolstered by CAMH's outstanding academic reputation; the McCain Model may be more difficult to implement without the support of a highly regarded organization. On-going research and implementation of Y-APs is needed to further explore the factors necessary to success, as well as factors that may be adaptable to the local context.

| CONCLUSIONS
This paper describes the McCain Model of Youth Engagement and youth-adult partnerships, illustrating an effective process for engaging youth in mental health and addiction research, planning and system building. Through flexible engagement and mentorship, the McCain team has created an environment of reciprocal learning and authentic shared decision making that has benefitted youth and adults alike. The team's research projects, presentations, conferences and media visibility have been enhanced and made more accessible to youth as the Y-AP has grown into an evidence-informed partnership that draws on the unique skills and knowledge of all those involved.
Health-care organizations interested in engaging youth can learn from the McCain Y-AP experience to guide their engagement initiatives and maximize success.