A Difficult Passage: Helping Youth with Mental Health Needs Transition into Adulthood

By Michelle Herman

September 2006

For questions or comments, send an e-mail to Donna Folkemer, Group Director, Forum for State Health Policy Leadership.

What Helps?
Some States Taking Action
A Model Program
A System-Wide Step
Acknowledgments

For most teenagers, turning 18 or 21 years old is a milestone of accomplishment and hope, ushering in the start of an advanced education or a career. But for young adults with mental health conditions (such as attention-deficit/hyperactivity disorder, schizophrenia, major depressive or anxiety disorders, or conduct disorder) the transition from adolescence to adulthood can be much more difficult. The dangers of ending up jobless, homeless or even in jail loom large.

More than 3 million young adults aged 18 to 21 have been diagnosed with a serious mental health condition. Almost 70 percent of high school students with identified mental health needs have vocational or employment goals, but more than half of these end up dropping out of high school, and only 5 percent to 20 percent enter postsecondary education, according to a soon-to-be published national study of youth in 500 school districts.

Young people with mental health needs who want to work or to utilize vocational training after high school are much more likely than students with other disabilities (such as physical impairments) to be disappointed in their dreams, according to experts in the field. “Across all disability groups, youth with mental health conditions have the worst long-term outcomes if you look at employment, incarceration and post-secondary education,” said Dr. Hewitt “Rusty” Clark, director of the Systems Development and Evaluation Team at the National Center on Youth Transition in Behavioral Health, in Tampa, Florida.

Securing employment – and the confidence that results from job competence – is crucial for youth to become well-adjusted adults with healthy self-esteem. If skills such as showing up for work on time and completing tasks are not developed in youth or young adulthood, it’s unlikely they’ll be developed later in life, said Maryann Davis, an expert on this issue and an assistant professor at the University of Massachusetts Medical School.

Failing to help youth successfully transition to adulthood can be costly to individuals and governments in the long run. It’s estimated that 90 percent of adults with serious mental health needs are unemployed – the lowest rate of employment of any group of people with disabilities. Young people aged 18 to 21 with a serious mental condition are three times more likely to be involved in criminal activity than youth without this type of disability. Those who don’t get help may then end up in prison.

What Helps?

If youth with mental health needs are to become responsible adults, they may need access to “developmentally appropriate” services – programs that are geared toward helping them become fully functioning, responsible adults. Such programs – which Davis calls “necessary prevention services” –include mental health services, as well as assistance in finding employment and housing, job training and education in daily living skills.

But many obstacles stand in the way of enrolling kids in such programs. Financing services is always a problem. Then there’s the fact that few states offer programs that are truly developmentally appropriate: young adults often are placed in mental health programs with people of all ages, despite having different developmental needs. Gearing services to young adults is important in part because their self-esteem depends significantly on peer and public acceptance, said Clark. “If a young adult referred to age-inappropriate programs enters a room and finds a group of 35 to 65 year-olds, they may feel distressed,” he explained. “They are not with their peers, nor is it how they envisioned their lives as older adults.”

In addition, there’s the problem that adult and child mental health systems often use differing definitions of serious mental health needs. Many states’ mental health programs have different diagnostic and functional impairment criteria. The fact that these criteria are generally narrower for adults may prevent young adults who were able to receive child mental health services from receiving them in the adult system.

Another complication is the fragmentation in programs and funding: mental health services are no longer provided solely in the mental health arena. Systems that provide mental health services include child welfare, housing, employment, juvenile justice and education, and funding mechanisms include Social Security, state and local appropriations, Medicaid and federal block grants. Many programs have divergent attitudes toward treatment and recovery, and they may not have effective ways of communicating with each other. Thus, users of several systems must navigate a labyrinth of financing streams, as well as conflicting rules and regulations.

Sometimes, youngsters fall into the gap that may exist between programs for children and programs for adults. Child-focused programs – such as Medicaid mental health benefits and child welfare benefits – often have differing eligibility requirements than programs for adults – such as state pharmaceutical assistance programs and adult vocational rehabilitation. If youngsters who “age out” of child-geared programs are to continue to receive services, they often must reapply as adults to adult programs. The confusing differences in eligibility rules, or any of the difficulties listed above, can be an insurmountable obstacle for youth with severe mental health needs, and can lead, at worst, to deterioration of mental health and to loss of employment and dropping out of school.

Some States Taking Action

States are taking a wide variety of approaches to these obstacles. Massachusetts and New Jersey, for example, reworded the definition of serious mental health condition and program eligibility criteria to help youngsters transition more smoothly between youth and adult mental health systems.

The Maryland General Assembly tackled the lack of coordination between different state agencies and programs by passing a bill directing the Maryland Department of Education and Department of Health and Mental Hygiene to develop a plan to improve both the adult and child mental health systems. The results include a state-supported education initiative at a community college and a specialized case management program for transitioning youth.

Some states have bridged the gap between child and adult mental health systems by grandfathering the eligibility of some or all children involved in the child mental health system into the adult system. Oklahoma has very broad eligibility standards: children in the mental health system are automatically eligible for adult services if they qualify by income. In Montana, 17 year-olds who probably will qualify for adult mental health services can receive children’s services until they are 21 years old. The state also lowered the age requirement for specialized adult services to 16 so that teenagers in need can begin receiving targeted case management.

Georgia developed a protocol to begin helping teenagers transition to adult programs on their 17th birthday and is working on a demonstration for 17 to 25 year-olds that will combine child and adult mental health services, and will provide federally subsidized housing.

Clark recommends that states offer a full array of services based on one’s mental health needs assessment, instead of requiring several systems to determine if children still qualify for specific services once they become adults. “States spend a tremendous amount of time justifying to agencies why young adults need specific services,” he commented.

In addition to providing easier access to mental health services, many states are developing job programs. Some states have programs to provide technical assistance for businesses that want to offer employment to young people with mental health needs. Others, such as a regional group in Maine, place mental health agency staff in close proximity to One-Stop-Shop Career Centers. These centers provide employment assistance to the general population, and the blending of the groups served may decrease the stigma associated with seeking separate, mental health-specific services.

A Model Program

A number of states are adopting a model program developed at the University of South Florida under Clark’s direction. The Transition to Independence Process (TIP) system is an evidence-based program that stresses the importance of providing access to appropriate services, engaging young adults in their own future planning process and utilizing services that focus on each individual’s strengths.

“Transition facilitators” connect young people with mental health needs and their families to programs that teach skills for finding employment, continuing their education, and/or learning how to live independently in the community. The facilitators have considerable flexibility to mix and match services across delivery systems to best suit individuals’ needs and to secure services quickly. Staff are trained to ensure that young adults participate only in services in which they are fully engaged, which saves administrative and service costs that might be otherwise spent on services that are not desired or useful.

Researchers in 2004 evaluated Vermont’s Jump on Board for Success (JOBS) program, a TIP-based program that helps 16 to 21 year-olds with serious emotional disturbances to secure employment, develop living and job skills, and decrease their use of public assistance. The program provides innovative employment and intensive case management services for at-risk youth. When researchers compared young people who had started the program with those who completed it, they found that 57 percent more kids who completed the program graduated from high school or obtained a GED, over 150 percent more obtained employment, and 70 percent fewer were involved in the criminal justice system or received Social Security or welfare benefits. Because JOBS participants were diverted from other types of public assistance, researchers estimated that in 2000, the program saved the state government $687,912 in foregone corrections expenditures, $42,336 in unneeded welfare benefit expenditures, and $37, 911 in foregone social/supplemental security benefit spending.

A System-wide Step

Connecticut has taken a comprehensive approach to the issue. As of early 2005, Connecticut was the only state to require that all adult mental health programs offer developmentally appropriate services to young adults, according to Davis. While a number of state child mental health systems have reached out to transitioning youth, not many adult systems have.

Connecticut’s adult mental health system provides Young Adult Services, a TIP-based program that helps young adults aged 18 to 25 gain the skills (such as getting and maintaining a job and housing) needed to function independently in the community. The state’s child mental health system collaborates with the adult one to help youth transition into Young Adult Services.

Sheryl Breetz, director of Connecticut’s North Central Regional Mental Health Board, credits the state Legislature as having been helpful in targeting services to transitioning youth. “Our legislators were receptive and willing to listen to constituents – including young adults and their families – to really understand what the issues were and why age-specific services mattered,” she said.

“This is a time in life when young adults shore up skills to be productive members of society,” commented Davis. “If we don’t provide help to these kids who really need it, we are missing this important opportunity and sending them on a much poorer trajectory in adulthood than is acceptable or necessary.”

Acknowledgments

This document was developed by the National Collaborative on Workforce and Disability for Youth (NCWD/Youth) and the National Conference of State Legislatures (NCSL), funded by a grant from the U.S. Department of Labor, Office of Disability Employment Policy (Number #E-9-4-1-0070). The Collaborative is charged with assisting state and local workforce development systems to integrate youth with disabilities into their service strategies. Information on the Collaborative can be found at www.ncwd-youth.info/. This Brief is a prelude to a forthcoming guide to be published by NCWD/Youth this fall entitled “Tunnels and Cliffs: A Guide for Workforce Development Practitioners and Policymakers Serving Youth with Mental Health Needs.” The opinions expressed herein do not necessarily reflect the position or policy of the U.S. Department of Labor. Nor does mention of tradenames, commercial products, or organizations imply the endorsement by the U.S.

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