Putting the Cart before the Horse: A Qualitative Validation Study of the Cascade-of-Care Framework In Youth and Young Adult Mental Health

Background: The Cascade-of-Care (CoC) framework, an approach that can improve targeting and efficiency in service provision, has recently been applied to youth behavioral health. However, no qualitative validation study has examined its relevance among critical constituents (e.g., young people, providers, administrators). Using a community participatory approach, this study asked whether the HIV CoC framework translates to youth mental health, and what barriers and facilitators shape treatment access and engagement along the pathways to and through care.

Method: Our team conducted 12 interviews and two focus groups with administrators, providers from community-based settings, and young people (N = 21) from two urban large behavioral health organizations. Participants were recruited purposively across constituent roles. Providers were 85% female, 15% non-binary, 77% White, with, on average, 4 years experience. Youth were 66% female, 16% male, and 16% non-binary, 100% Black and/or Latinx (mean age = 17). Thematic analysis was conducted in Atlas.ti: two analysts coded transcripts independently, reconciled codes and built consensus, with an additional secondary coder facilitating reflexive discussions and resolving disagreements.

Results: Three themes emerged in the data.

1: Friends/Technology as Key Facilitators: Revisiting the Gateway Providers. Peers, not clinicians, functioned as the primary entry point into services. Staff and young people converged on this: “I think a lot of times, what brings people here is their friends — hey, there’s a lot of free services.” Technology, including AI chatbots, also emerged as a low-stakes first resort.

2: Stigma: Built Around the Dinner Table, Broken Down in the School Cafeteria. Stigma emerged as one of the main barriers discussed. It occurred within families and cultural communities but was partially countered in school and agency settings: “When my family knew I was in therapy, they excluded me and made me feel like the black sheep. I was 11.”

3: Moving Beyond a Diagnosis: The Importance of Being Seen in Friendship. Peer recognition of distress, not formal screening, was the most frequently described pathway to early identification. Young people expanded conditions that warranted support beyond diagnosable conditions through their peers noticing: feeling “out of it,” or “not quite themselves.” “If your friend is normally always talkative or has high energy, you could notice if they’re going through something — you could just tell.”

Discussion: Data support the HIV CoC framework’s applicability to youth mental health, while revealing places for revision. The cascade’s early stages (need identification, referral, and linkage) are mediated primarily through peers, suggesting the Gateway Provider Model expand beyond formal referral systems to account for friends and digital platforms as entry points. Stigma, a potential barrier at every point on the CoC, is not a fixed individual-level barrier; it is shaped by family, culture, and organizational context, and non-clinical settings can partially dismantle it. Young people’s broader threshold for recognized need, extending beyond diagnosis to subclinical distress, further advances the CoC which positions clinical encounters as the primary site of identification. Findings suggest community-based organizations offering peer-informed, low-barrier entry may move youth further along the treatment cascade than clinically-oriented referral alone.