Making Services and Supports Work For Youth and Young Adults With Mental Health Needs Who are Transitioning to Independence

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Given the overwhelming need to create transition systems that support youth as they move into adulthood, this month Data Matters is highlighting two main features. The first feature profiles the Partnerships for Youth Transition initiative funded by SAMHSA in 2002 to fund five sites across the nation to develop and implement transition programs for youth with mental and emotional difficulties as they enter adulthood. The second feature shares some lessons learned from youth, families, and transition providers on how to develop new transition programs.

Moving from adolescence to adulthood — leaving home, going to school or work, buying a house, perhaps starting a family — is a significant transition for anyone. For the more than 3 million young adults diagnosed with serious mental health conditions, the pathway into the adult world is even more challenging.

Youth and young adults who have been diagnosed with a Serious Emotional Disturbance or Serious Mental Illness (SED/SMI) such as major depressive or anxiety disorders, attention deficit disorder, schizophrenia, or conduct disorder face a number of risks and challenges as they struggle to become adults:

• Over 60 percent of young adults with a serious mental illness are unable to complete high school. These young adults are often unemployed, unable to participate in continuing education, and lacking in skills necessary for establishing and maintaining supportive relationships and independent living.
• Transition-age youth with SED/SMI have higher rates of substance abuse than any other age groups with mental illness.
• Adolescents entering adulthood with SED/SMI are three times more likely to be involved in criminal activity than those without an illness.
• Serious mental health conditions in adolescence generally continue into adulthood. Young adulthood is also a high-risk period for developing new disorders.

When young people with SED/SMI reach their 18th or 21st birthdays, they face arbitrary disruptions in their care. Because of their age, they often lose eligibility for continuing care in the child mental health system that has served them, ending ongoing caseworker and therapeutic relationships. Only a fraction of these young people meet the typically narrower eligibility criteria for accessing adult mental health services.

Matching Services to the Needs of Young Adults
In addition to continuity of care, young adults need services that are developmentally appropriate and specific to the distinct needs of a young person just entering adulthood. Too often, mental health and other services are not designed with the needs, interests or goals of young adults in mind.

Principles of Developmentally Appropriate Practice: Transition to Independent Process (TIP) Model

1. Engage young people in a relationship with a caring, responsible adult to plan for their own future.
2. Tailor services and supports to be accessible, coordinated, developmentally appropriate and to build on strengths.
3. Respect young people’s developmentally appropriate search for independence and social responsibility by acknowledging personal choice and their need to find their own way.
4. Ensure a safety net of support, including family, to reduce risks.
5. Strengthen young people’s competencies to assist them in achieving greater self sufficiency and confidence.
6. Help the young person maintain a focus on outcomes, and encourage programs and systems to do the same.
7. Involve young people, parents and other community partners in the TIP system at all stages and levels.
   (For a complete description of the TIP model, see the TIP System Development and Operations Manual http://tip.fmhi.usf.edu/).

In addition to continued access to appropriate mental health services, many young people need transition supports and assistance in finding employment, housing, job training and education. At the same time, policies and programs must respect a young adult’s developmentally appropriate need for greater independence and greater control over goals, services and life decisions.

When asked their priorities for assistance, youth with SED/SMI identified the following areas:

• Finishing school and career training
• Finding a decent job
• Learning independent living skills
• Management and living within a budget
• Finding an affordable, safe, and comfortable home
• Dealing with their family issues

Seeking Effective Solutions: Partnerships for Youth Transition Initiative (PYT)
In September 2002, the Substance Abuse and Mental Health Services Administration (SAMHSA), Center for Mental Health Services (CMHS), in partnership with the Department of Education, Office on Special Education Programs, awarded approximately $2.5 million per year for four years for the Partnerships for Youth Transition (PYT) initiative. This initiative funded five sites across the nation to develop and implement transition programs for youth with mental and emotional difficulties as they enter adulthood.

Snapshots of PYT Sites
Allegheny County Department of Human Services—Pittsburgh, Pennsylvania
The Allegheny County PYT project operated in two economically disadvantaged communities, serving young adults 14 to 25 years of age. As with the other PYT projects, this site relied heavily on transition facilitators to work proactively and intensely with young people, engaging them in a “futures planning” process to help determine their goals and the local services available in their community to help them reach these goals.

In addition to these facilitators, the site established “family specialists” to help parents and other family members understand the transition process and address their own family needs. The PYT site leadership partnered with secondary schools, church leadership, community colleges and other formal and informal community entities to provide an array of services and supports to assist transition aged youth.

Clark County Department of Community services and Corrections—Vancouver, Washington
The PYT site found some early gains by examining state policies and regulations for funding transition-related services. While there were many real barriers to young people continuing their mental health treatments, this review exposed some that were based primarily on myth or misperceptions. The effort yielded funding benefits. For example, young adults who were previously in child welfare were automatically qualified for Medicaid funding for adult mental health services.

Maine Department of Health and Human Services, Departments of Vocational Services and Psychiatry, Maine Medical Center—Augusta, Maine
PYT staff engaged youth who were hospitalized for the first time. Interventions (and outcomes measured) centered on domains critical to making a successful transition into adulthood: completing secondary education, entering into postsecondary education, finding and retaining employment and stable housing, and family psychoeducation. Because this disability group has the highest high school dropout rate, the PYT staff worked intensively with school staff to make re-entry a smooth process, wherein the student felt supported and welcomed.

Utah Department of Human Services—Greater Salt Lake area
The State Youth Action Council reviewed policies, procedures, and service design and
organized annual events to bring program participants together for leadership development. Young people identified the lack of affordable housing as a key barrier to independence. Youth worked with corporate leaders to establish new housing units in an apartment complex with subsidized rents and support services, including a communal kitchen and meals.

Pact-4 Families Collaborative—Willmar, Minnesota
The PYT program identified transportation as a significant challenge for youth in rural areas. Arranging for transition facilitators to transport youth to job shadowing experiences, health appointments, and interviews carried the additional benefit of "windshield time," providing time for the facilitator and youth to work together to identify goals and create a more individualized transition plan; e.g., earn a GED, enroll in community college, learn to self-manage medications, and/or earn a driver’s license.

PYT Makes a Difference
The National Center on Youth Transition team* is conducting cross-site analyses of the PYT projects. Over time, these young people were:

• More likely to be employed and to be pursuing high school or postsecondary education.
• Less likely to have dropped out of high school and less likely to experience interference in their lives from their mental health conditions or from drug or alcohol abuse.

Full text can be found at http://www.connectforkids.org/PYT_brief.pdf

The National Center on Youth Transition at the University of South Florida maintains a website with contact information and links to the Partnerships for Youth Transition websites as well as updates on research and programmatic developments.
http://ncyt.fmhi.usf.edu/index2.cfm

1. Positive Philosophy
Being clear on program philosophy seems to be key to success. Examples of program philosophies associated with positive transitions include:

• Treating young people as emerging adults.
• Belief in recovery—that young people will go on to lead productive lives.
• High expectations—belief that young people can be successful in careers, college, vocational training, and jobs of their choice.

2. Flexibility
Effective transition programs need:

• Flexible developmentally appropriate programming, adapted to meet young people’s evolving needs and to take advantage of “teachable moments.”
• Multiple options to prepare for employment, depending on young people’s skills, interests, and levels of preparedness, including portfolio and resume preparation, contact with mentors, job shadowing, practice interviewing, apprenticeships, and supported employment.

3. Respected and Experienced Staff
In addition to communicating effectively with young people, it is advantageous for staff to have the respect of other service providers. This is particularly important if the transition program is housed alongside more structured child treatment programs, so that child treatment staff will appreciate the less structured transition approach.

4. Youth and Family Leadership
The balance between family voice and young people’s leadership is likely to vary from one program to another depending on young people’s needs and preferences.

5. Transition Program Activities
If interventions are clearly defined, linked with a coherent program philosophy, and communicated, then expectations will be realistic and outcomes can be evaluated.

6. Transition Program Eligibility
If transition program staff need are clear about who is eligible and who they expect to serve most effectively, then young people who are most likely to benefit will be able to participate. Age, level of disability, level of substance abuse, and goals of young people are useful eligibility criteria to consider.

7. Community Partnerships
Collaboration needs to be community wide, based on a shared mission and philosophy, and extend beyond mental health services to include contacts with vocational, housing, health, and disability services.

8. Whatever it Takes
Young people need staff who are willing to persevere, even when young people seem unappreciative or when their progress seems to have stalled.

9. Building on Young People’s Strengths
Staff who believe in young people’s abilities and respect their goals will be more likely to build on their strengths. Young people benefit from staff’s commitment to providing pro-social activities and connections to opportunities for volunteering, internships, work on community projects, so that youth learn that they can make positive contributions to society.

10. Continuity of Staff
Staff retention is especially important. Young people benefit from staff committing to the work for the long haul because commitment is essential and young people need to be able to engage with someone who will be there over a period of time—possibly several years.

For full text visit
http://www.rtc.pdx.edu/PDF/pbTI-StartingPointsForNewTransitionPrograms.pdf

Jivanjee, P., Koroloff, N., & Davis, M. (2008). Starting points for communities developing new transition programs for young people with mental health difficulties. Portland, OR: Research and Training Center on Family Support and Children’s Mental Health, Portland State University.

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Has anyone instituted an initial cost analysis on these concepts in respect to current federal funding steams? (07/08/09)

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