1. Transition to Adulthood Maryann Davis, Ph.D. Center for Mental Health Services Research University of Massachusetts Medical School Research funded by NIMH R01-MH6786203, Center for Mental Health Services and National Association of State Mental Health Program Directors

2. Session Overview Why do we need to improve transition support services? Whats so special about transition? Developmental Stage Youth Culture System Alignment How can we do better? Practice Guidelines Policy Guidelines

3. Valdes et al., 1990; Wagner et al., 1991; Wagner et al., 1992; Wagner et al., 1993; Kutash et al., 1995; Silver et al., 1992; Vander Stoep, 1992; Vander Stoep and Taub, 1994; Vander Stoep et al., 1994; Vander Stoep et al., 2000; Davis & Vander Stoep, 1997 Youth with Serious Mental Health Conditions Struggle as Adults Mental HealthGeneral Population Finish High School EmployedHomelessPregnancy

4. Proportion Arrested Throughout Transition Period; MH vs General

5. Why should we improve transition supports? Many young people with serious mental health conditions are failing in young adulthood This level of functioning reflects services as usual Services as usual not making enough of a difference

6. Whats so special about the transition period?

7. New Stage of Development Transition sits between mid-adolescence and mature adulthood – roughly 14/16- 25/30 Services for adolescents or mature adults not appropriate for this age group Have unique developmental challenges Psychosocial development Economic/Societal context

8. Psychosocial Development Psychosocial Development Adolescence to Adulthood Developmental change on every front

9. Thinking hypothetically; "If I become pregnant I probably won't finish high school, but my boyfriend might marry me, but if he doesn't......." Planning for the future; "Before I get an apartment I need to get a job, save money, and work on a budget." Insight into themselves; "Every time an older man questions what I do I get terribly angry - he reminds me of my father." Reflects a Growing Ability for Abstract Thinking; These changes allow them to examine their choice process, and have a better understanding of themselves and others.

10. Typical Social Development Peer relationships are of PARAMOUNT importance. Friendships become more complex, involving mutuality, intimacy, and loyalty.

11. Social Maturity; Development of Sexually Intimate Relationships New types of intimacy Life-impacting and safety issues Address sexual orientation

12. Social Maturity; Changes in Family Relations Young people and parents must adjust to the growing need for independence while remaining emotionally related Relationship remains important, shifts to adult-to-adult (involving empathy, intimacy, loyalty, mutuality)

13. Typical Moral Development Externally reinforced rights and wrongs Rigid interpretation (applies to everyone in all situations) Empathic responses & Golden Rule Sacrifice for the greater good

14. Typical Identity Formation Answering the question; Who am I? Who am I that I am not my Parents? Who am I as a student, worker, romantic partner, parent, friend? Who am I in the World? What do I like to do and who do I want with me?

15. Biopsychosocial Development in Youth with Serious Mental Health Conditions With the exception of sexual development, as a group, youth with serious MH conditions are delayed in every area of biopsychosocial development.

16. Psychosocial Delay Impacts Functioning Developmental changes accumulate gradually over time Developmental changes underlie increased functional capacity Functional capacities build gradually over time

17. Young Adults have Less Mature Functioning than Mature Adults * 2 (df=1)=31.4-105.4, p<.001 ** 2 (df=1)=5.5, p<.02

18. Younger-Older Adult Differences In School

19. Younger-Older Adult Differences Living with Parents

20. Psychosocial Maturity comes from Social Interaction Cognitive maturation; ability to think abstractly and apply that abstraction to social environments Dependent on social interaction and social demand Our brains have not changed but our social interaction and society has CREATING NEW STAGE; EMERGING ADULTHOOD

21. Transition has Changed in Society Bachelors degree is the economic equivalent of high school degree in the 60s Fewer opportunities to earn incomes that allow for independence (with college degree) Unaffordable housing More dependence on families for longer time (Settersten, Furstenberg & Rumbaut, 2004)

22. Transition as Cultural Competence

23. Each Generation has its Youth Culture "In America, a flapper has always been a giddy, attractive and slightly unconventional young thing who, in [H. L.] Mencken's words, 'was a somewhat foolish girl, full of wild surmises and inclined to revolt against the precepts and admonitions of her elders.'" 6

24. Yippies, Hippies, Yahoos, Black Panthers, lions and tigers alike - I would swap the whole damn zoo for the kind of young Americans I saw in Vietnam. Spiro T. Agnew American vice president

26. Culturally Competent Service Guidelines Respect On staff Education and training Culture data collected and integrated in MIS Develop participatory collaborative partnerships with youth community Develop, implement & promote organizations plans to develop youth competent services http://home.fmhi.usf.edu/content/EmployeeResources/natlStandardsforDiversity.pdf

28. Point of Transition; Child and Adult Systems AGE Child Mental HealthAdult Mental Health Child Welfare Special Education Juvenile Justice Criminal Justice Substance Abuse Vocational Rehabilitation Housing

29. Segregated Child and Adult Systems 1.Lines of communication are limited 2.Different cultures 3.Different eligibility criteria 4.Few transition support services in both systems

30. Segregated Child and Adult Systems; Lines of Communication Serve children Serve adults Block analysis of Clark County PYT; prior to grant implementation Johnsen et al., 2005

31. Different Cultures CHILD MH Family focus Parent Partnership Work with many systems Comprehensive approach Developmentally aware coddles ADULT MH Individual focus One-stop system Rehabilitative No developmental perspective Not supportive

32. Of Care Based on written policies received from 45 states From Davis & Koroloff, (in press)

33. Child & Adult Mental Health Population Policy Differences From Davis & Koroloff, (in press)

34. Population Policy Differences No state had the same population policy for child and adult mental health Generally, child definitions/criteria are broader Produces arbitrary barrier of access to adult services based on a change in age, not on a change in need. Grandfathering corrects for those in the system, but not for new young adults

35. Consequences of Population Policy Differences Systems are built around their target population, underlies many of the conflicts between child/adult systems Supports the false dichotomy of adulthood/adolescence Circular argument that you provide services to priority population, and you dont others because others arent served well Denies ownership of the whole mental health population

36. Distribution of Programs by Age Groups Served (n=103) Youth Only Adults Only 14-25 yr olds Continuously 14-25 yr olds Discontinuously Youth Only=up to 18 or 21, Adult Only=18 or 21 and older

37. Continuity is Lacking For 46% of service types (56 types), not a single program in this Transition Network offered that service to 14-25 year olds continuously (i.e., without requiring a change in program or staff) Of the 789 individual services offered in the Transition Network, 99 (12.5%) offered continuity from ages 14-25

38. From Davis, Geller, & Hunt (2006)

40. Exemplary Practices Exemplary transition support practices (e.g. TIP System) require a policy framework that allows for Continuous services Developmentally appropriate services Services guided by youth and young adult input Comprehensive services that address the needs of youth and young adults with serious MH conditions and their families. http://tip.fmhi.usf.edu/

41. General Pattern 1)Service provider becomes aware of problem 2)Often identified in conjunction with other stakeholders 3)Service provider takes lead in fleshing out problem and solution 4)Sometimes finds small initial funding source 5)Approaches major funder; long standing and trusting relationship 6)Funder determines that solution not too painful; not much more money and no policy changes implied

42. Central Policy Tenets I.Provision of continuity of care from ages 14 or 16 to ages 25 or 30. II.Support of family role to ages 25-30. III.Provision of continuity of care across the many systems that offer relevant services. IV.Promotion of a density of developmentally- appropriate services from which individualized service and treatment plans can be constructed. V.Support of expertise in this age group and disability population.

43. Factors State Adult Administrators Identified as Needed to Improve Transition

44. TRANSITION-FOCUSED WEB SITES. National Technical Assistance Center on Youth Transitions http://ntacyt.fmhi.usf.edu/index2.cfm The Network on Transitions to Adulthood http://www.transad.pop.upenn.edu/ OTHER LINKS Links from the National Technical Assistance Center on Youth Transition http://ntacyt.fmhi.usf.edu/links/links.cfm PAPERS BY M. DAVIS & COLLEAGUES http://www.umassmed.edu/cmhsr/working_papers/index.aspx Transition web sites