Improving Post-School Outcomes for Youth with Mental Health Issues

1. Improving Post-School Outcomes for Youth with Mental Health Issues Mason G. Haber, Ph.D. Department of Psychology University of North Carolina at Charlotte

2. Youth Voices “For me personally, I had no interest in the typical college experience” “After my experience in the crisis hospital unit, I found myself engaging in Options more fully and starting to make a lot of progress in my transition. I was able to get my G.E.D. (the “Good Enough Diploma”.) That was a big moment for me. I was always told that if I didn’t walk with my graduation class, I was nothing and would never amount to anything. “It was very helpful to me when my caseworker, my mother, and I all got on the same page. We worked really well together, and this made me feel that we had a good plan” “I needed to be taught to become an adult not when I was 18 but when I was 12,15, or 16. Now that I’m 18 in New York City, I’m no longer eligible for the programs I still need. I have nowhere to go. I need to learn to balance a checkbook, maintain an account, pay my bills, and clean my apartment. I needed to start learning these skills more than just 2 months before my 18th birthday. Taken from: Clark, H.B. & Davis, M. (2000). Transition to Adulthood: A Resource for Assisting Young People with Emotional or Behavioral Difficulties. Baltimore, MD: Brookes; Clark, H.B., & Unruh, D.K. (2009). Transition of youth & young adults with emotional or behavioral difficulties. Baltimore, MD: Brookes

3. Understanding Outcomes of Youth with Mental Health Issues • These youth voices illustrate key predictors of post-school success or failure for youth with mental health issues (MHIs): • “Nontypical” learning experiences • School completion, both standard and nonstandard • Family involvement • Training in basic skills • Identifying these predictors is the first step toward improving outcomes • Data on predictors are a necessary complement to data on evidence-based practices

4. Objectives • Today’s talk will focus on research predicting post-secondary outcomes of youth with MHI & its implications • Specifically, we will describe: • existing research on post-secondary outcomes of youth with mental health issues (MHIs) • research on predictors of outcomes of youth w/MHIs • research and best practice guidelines for improving post-secondary outcomes of youth with MHI • policies to improve post-secondary outcomes

5. Why Focus on Predicting Post-secondary Outcomes? • Predictors of in-school success may not translate to post-school gains • Questions to answer: • Which factors predictive of in school improvement also result in success post-exit? • Which programs or practices impact both in school and post-school outcomes? • Which targets for programs (e.g., skills) are most associated with improved post-school outcomes (i.e., mediators?)

6. Why Focus on Predicting Post-secondary Outcomes? Test et al. (2008). Evidence-based Secondary Transition Practices and Predictors.

7. Post-secondary Outcomes:Types and Timing • Measures of employment • Measures post-secondary educational experiences • Combined measures (e.g., “productivity” or “engagement”) • Other types of indicators(e.g., independent living, quality of life) • Indicator 14 & beyond • Transition continues past post-exit year 1, so these “outcomes” are predictors as well • Outcomes are also linked(e.g., employment may drive or inhibit education)

8. Types of Mental Health Issues • Pervasive dysregulation (i.e., SED/EBD) • Clinically significant depression or anxiety • Severe or complex traumatization • Delinquent/illegal behavior, including substance use/abuse • Dual diagnoses, including other disabilities (e.g., ID, LD) • Adjustment issues • Emerging or prodromal psychotic disorder Synthesis Inc. (2006; 2009)

9. Youth with “Disability” vs.with “Issues” • For MHIs, the disability label may be particularly stigmatizing (Clark & Davis, 2000) • Disability label may not be a fit; even “severe” issues may not be lifelong (Burt & Masten, 2010) • Focusing on MHIs is inclusive of youth who could benefit from secondary prevention • e.g., as part of a comprehensive school-based mental health plan(Simonsen & Sugai, 2009) • Although our focus today is on youth classified as disabled, a wider continuum should be addressed

10. Common Challenges • Developmental Transitions • Institutional Transitions • These transitions may be particularly problematic for youth w/MHI • “Unique” factors • Disability reflects meta-cognitive deficits • Strain on relationships w/adults • “Invisibility” of disability • All of these impact post-secondary outcomes Davis, Green, & Hoffman (2009); Davis & Vander Stoep (1997); Podmostko (2007)

11. Post-secondary outcomes of youth with MHI • Comparisons groups can include own-age peers or youth w/other disabilities • Youth w/MHI vs. other disabilities have • Poorer employment outcomes • Lower % of secondary school completion • Lower % in post-secondary education • Much higher rates of negative outcomes • e.g., criminal justice, drug use, pregnancy

12. Post-secondary outcomes of youth with MHI Table 1. Outcomes of Youth with MHI, All Disabilities, & General Population Adapted from Clark & Unruh (2009)

13. What Predicts Outcomes? – Kohler’s Taxonomy Student Program/Family System Adapted from Kohler (1996)

14. Predictors of Outcomes – NSTTAC meta-analysis • Test et al. (2009) reviewed studies on predictors of post-secondary outcomes for all youth w/disabilities • Three outcomes: Employment, Post-secondary Education, & Independent Living • Studies were coded by Kohler taxonomy category • Coding has just been completed for a meta-analysis and extension of this study (N = 36 studies) • What has been found in the studies focusing on youth w/ MHI? Test, D., Mazotti, A., Mustian, A.L., Fowler, C.H., Kortering, L., & Kohler, P. (2009). Evidence-based secondary transition predictors for improving postschool outcomes for students with disabilities. Career Development for Exceptional Individuals, 32, 160-181.

15. Predictors of Outcomes – NSTTAC meta-analysis • 2 studies!! • Study 1: A secondary analysis of NLTS-1(Rylance, 1998) • Predictors of employment: “Functional competence”; H.S. Diploma achievement (~10% of variance) • Vocational & counseling predicted only 2.54% • Study 2:“Steps to Success” (Karpur et al., 2005) • Participants later showed greater post-secondary enrollment than matched youth Karpur et al., (2005). Transition to adult roles for students with emotional/behavioral disturbances: A follow-up study of exiters from Steps-to-Success. Career Development for Exceptional Individuals, 28, 36-46; Rylance (1998). Predictors of post-high school employment for youth identified as severely emotionally disturbed. Journal of Special Education, 32, 184-192

16. Predictors of Outcomes – NSTTAC meta-analysis • N=20 studies had significant #s of youth w/ MHI (> 5%) or included all disabilities • Significant predictors were identified in all 5 Kohler taxonomy categories • By far, student development and program structure were best represented • Fewer studies focused on planning, family involvement, and coordination • Note that the former categories are program level factors, the latter, system-level

17. Predictors from NSTTAC Review • Student Developmentpredicted 3 outcomes (education, employment, and independent living) • Examples: career awareness, community experiences, diploma receipt, self-determination • Program structure(e.g., specialized transition programs) predicted education & employment outcomes • Planningpredicted education outcomes • Family involvementwas only examined in a study focusing on learning disabled youth • Collaborationpredicted education outcomes Test et al., (2009).

18. Findings from Scientific Proceedings (Karpur, Haber, & Clark, 2007) • Karpur et al. (2007) linked Florida DOE databases to predict outcomes 2 years post-exit • Youth w/MHIs analyzed separately • Predictors: diploma type & service utilization • Findings: • Certificates & nonstandard diplomas improved employment and education outcomes • MHSA service utilization related to pooreremployment and education outcomes • Note, despite propensity scoring use to balance groups, MHSA youth may have more severe problems Karpur, A., Haber, M., & Clark, H.B. (2007). Utilizing statewide administrative databases to follow postsecondary outcomes for youth with emotional and/or behavioral disturbances. 20th Annual Conference of the Research and Training Center on Children’s Mental Health. Tampa, FL: University of South Florida.

19. Post-secondary Outcomes of Youth w/EBD by School Exit Type

20. Post-secondary Outcomes of Youth w/EBD by MHSA Service Use

21. Research on predictors:Implications • Youth w/MHI have poorer outcomes than youth w/disabilities overall • Student development predicts outcomes • Functional competence & diploma achievement (both standard & nonstandard) (e.g., Karpur et al., ’05, ’07; Rylance, 1998) • Programs focusing on transition issues (e.g., steps to success) predict better outcomes • Bridges to Work, TIP , RENEW • General vocational services, counseling, and MHSA predict weakly, at best

22. Research on Predictors:Implications • More research and evaluation of planning, family involvement, & interagency collaboration are needed. • Despite the lack of post-school outcome data, other types of evidence suggest these are promising areas of focus, including: • Data on role of family support among students in general, and also normal & vulnerable young adults • Data on wraparound and systems of care • Evidence-based practices w/similar populations • Best practice guidelines & promising program models

23. Family Involvement • Parent involvement relates to better performance on student & school levels • Research on young adults suggests financial independence is not achieved until 25 or later • Involvement by parents and other supportive adults also critical for youth w/MHI specifically • However, the role of family changes, and working with families may become more challenging • This has important implications for planning and interagency coordination Selected References: Haber, Cook, & Kilmer (2010); Hatter, Williford, & Dickens; Jivanjee, P., Kruzich, J.M., & Gordon, L.J. (2009).

24. Family & Youth Driven Wraparound? (Haber, Cook, & Kilmer, 2010) Caregiver Strain by Age of Youth in Wraparound Services

25. Family & Youth Driven Wraparound? (Haber, Cook, & Kilmer, 2010) CFT Processes Among Older vs. Younger Adolescents

26. Solutions? • In a recent review of wraparound child & family teams (CFTs) for a local transition program: • Intact CFTs performed poorly • Youth-identified CFTs were more dynamic • The best teams formed to respond to a futures plan created by youth with transition specialists. • In some cases, teams met only sporadically, had changing membership, or were not used. • In sum: team development proceeded best when tailored to youth driven plans D. Jackson-Diop (personal communication, May 17th ,2010).

27. Interagency Collaboration • Needs for interagency collaboration to support developmental transition of youth are clear • In transitioning to adulthood, youth experience many changes at once and have diverse needs • Institutional transitions/silos can also be disruptive • Well documented examples for youth w/MHI: • The siloing of child and adult mental health system • Siloing of mental health and substance abuse services is problematic due to high rates of co-occurring disorders • Reviews, expert opinion surveys, & case studies provide insights on improving collaboration (e.g., Haber et al., 2007; Davis et al., 2009)

28. Recommendations for Interagency Collaboration – Local • Placing personnel from other sectors in schools, starting from early on • VR, adult mental health, transition specialists, community college counselors, benefits counselors • Transition case review teams • Community Steering Committees • Youth voice and leadership are important • Mechanisms for blending funding Sources: Haber, M.G., Loker, T., Deschenes, N., & Clark, H.B. (2008). Career Development for transition-aged youth with emotional disturbances: Exemplary practices of Florida mental health and substance abuse agencies (ACHA series, 220-115). Tampa, FL: University of South Florida; Woolsey, L., & Katz-Leavy, J. (2007). Transitioning youth with mental health needs to meaningful employment and independent living. Washington, D.C.: NCWD/IEL

29. Recommendations for Interagency Collaboration – State • Interagency task forces and collaboratives • Learning communities • State-local partnerships (e.g., Healthy Transitions) • Youth summits • MA, Portland National Summit • Policies to address service silos(e.g., flexible reimbursement, addressing inconsistencies in eligibility criteria) • Technical Assistance to localities to use data more effectively(e.g., longitudinal data systems) Davis, M. & Konyagi, C. (2005). Summary of Center for Mental Health Services youth transition policy meeting: National experts panel; Haber et al., (2008); Koroloff, N., Davis, M., Johnsen, M., & Starrett, B. (2009). Under construction: Linkages between youth and adult systems. Rockville, MD: SAMHSA

30. Collaborative Program & System Models • Transition to Independence Process (TIP)(Clark, 1995, 2004) • Rehabilitation, Empowerment, Natural Supports, Education, and Work(RENEW; Malloy, Drake, & Couture, 2009) • Both of these models were specifically developed for youth with MHI • RENEW provides guidelines for use within a School-wide Positive Behavioral Support Program Clark, H.B. (2004). TIP System Development and Operations Manual. Tampa, FL: University of South Florida; Malloy, J. M., Drake, J., & Couture (2009). RENEW Facilitator’s Manual: Secondary Transition for Youth & Young Adults. Manchester, NH: University of New Hampshire.

31. Conclusions • Research on post-school outcomes identifies important factors, programs, and targets related to post-school success • Schools and communities can: • Evaluate programs by measuring in-school factors and targets related to post-school success • Use promising specialized transition programs such as TIP and RENEW, as part of a school-based mental health continuum of care • Attend to developmentally appropriate family involvement and care coordination, using models such as TIP & RENEW to guide these strategies

32. Conclusions • States can assist schools & communities by: • Providing technical assistance in measurement of in school variables most strongly related to outcomes • Promote dissemination of promising transition programs (e.g., by working with purveyors to provide centralized technical assistance) • Invest in longitudinal data systems to improve evidence-base on post-school outcomes and inform local efforts • Develop policies that address child & adult mental health as well as other service silos • Create post-school outcome focused statewide plans

33. Thank You!!