From Youth to Adulthood: Offering Help
Two months before Michelle's 18th birthday, the therapist she had been seeing for her bipolar disorder told her she was about to “age out” of Utah's publicly funded children's mental health system. As a result, she would soon be too old to see him or participate in the youth group where she had made strong bonds. She didn’t connect with a new therapist and soon fell into a depression that resulted in a suicide attempt.
When Michelle emerged from a state hospital after nine months of residential treatment, she wasn’t ready to be the adult the mental health system insisted she was.
In fact, she wasn’t really sure what was going on. On her first day out, a hospital staffer took her shopping. “I was trying to be nice by choosing cheaper things, because I thought she was reaching into her own pocket to buy me things,” said Michelle, who now realizes that the hospital had applied for public benefits on her behalf. When the staff moved her into a transitional apartment, she had no idea how the rent got paid or even how to get the power turned on. Soon after, she found herself homeless.
Now 24 years old, Michelle is working to make sure that other young people are better prepared for adulthood than she was. As she told participants at
Launched in 2009, the initiative helps young adults ages 16 to 25 with serious mental health conditions transition successfully into adulthood. The goal is to improve outcomes in such areas as education, employment, housing, mental health and community involvement, while keeping young people out of the juvenile and criminal justice systems. The seven states that received the five-year grants are Georgia, Maine, Maryland, Missouri, Oklahoma, Utah, and Wisconsin.
Falling Through the Cracks
Like Michelle, many young people with mental health concerns encounter difficulties once they’re no longer eligible for children’s mental health services.
“Families are usually not aware of the changes that occur around age 18 and are not provided with adequate education, resources and supports to provide guidance to their young adult,” said Project Officer Diane L. Sondheimer, M.S.N., M.P.H., C.P.N.P., Deputy Chief of the Child, Adolescent, and Family Branch in SAMHSA’s Center for Mental Health Services.
The services from which young adults typically age out include eligibility for children’s mental health services; case management; supervised, supported, or group home settings; educational support; specialized vocational support, preparation, and counseling; preparation for independent living; and social skills training. Like Michelle, they’re also forced to give up continuity of services, often having to change the staff they see or the programs they use, which can further exacerbate issues of depression and mistrust, and cause a lapse in services.
The transition to adult services is often rocky, said Ms. Sondheimer. “Young adults who are on their own have to go through a full disability 'redetermination' after reaching age 18 and often have difficulty negotiating the system without support and, consequently, may go without needed services and supports,” she said.
They may be unfamiliar with the way adult programs work, and adult programs may not follow up when young people miss appointments. Young people often have new demands on their time, such as school, work, or relationships. They may lose critical support from their families or the social safety net. Or they may just be experimenting with independence.
“This stage is a critical window of opportunity for young people to grow and prosper,” said Ms. Sondheimer. “With the right types and amount of support, these young people can have great success.”
A new report from SAMHSA’s Center for Behavioral Health Statistics and Quality reveals what happens when these young people don’t get that support.
For one thing, most young adults aren’t getting the treatment they need. Almost half of young adults ages 18 to 25 with serious mental illness haven’t received treatment in the past year, the report indicates.
Young adults with a serious mental illness can also find it hard to get a job, according to the report. While 12 percent of young adults without mental illness are unemployed, the report shows, more than 16 percent of those with serious mental illness lack jobs. Even when they do find employment, young adults with serious mental illness can find it hard to keep their jobs. They are much more likely than peers without mental illness to have had more than three employers in the past year.
Young people with mental illness also find it hard to maintain stable housing, which makes it hard to keep a job or receive consistent mental health services. More than 15 percent of young adults with serious mental illness moved three or more times in the past year, compared to 6.7 percent of young adults without mental illness.
Supporting Emerging Adults
The Emerging Adults Initiative helps prevent these negative outcomes. “The overall goal is to transform the system so it seamlessly provides services that meet young people’s developmental needs and help them succeed in adulthood,” said Ms. Sondheimer. Grantees have been busy developing state frameworks in three key areas:
- Collaboration. The program emphasizes collaboration both within and across agencies. One critical component is collaboration between child- and adult-serving systems.
- Policy development. The grantees are also working to develop policies that will be adopted system-wide and sustain the youth-in-transition services they create.
- Practice models. Grantees use evidence-based or research-informed practices to improve emerging adults’ outcomes in such areas as education, employment, and living situations. Practices may include peer support services, trauma-informed care, and supported education, employment, and housing.
Ms. Sondheimer points to Utah’s program as one example of what states or communities can achieve.
"When the Utah Division of Substance Abuse and Mental Health started investigating, it found that an alarming number of young people with mental health issues were failing to make the transition from programs serving children to those serving adults", said Ming Wang, L.C.S.W., Principal Investigator and Project Director of Utah’s Emerging Adults Initiative.
In some cases, she said, they were simply unaware of the adult system. In others, they tried the adult system and found it a poor match for their needs. In the children’s system, for example, young people receive services focused on skills development. Once they reach age 18, however, they may be referred to a community center where they find older adults with whom they have very little in common.
“Our adult system is really geared toward adults who are 35, 40, or older and who have chronic mental illness,” said Ms. Wang. “It’s easy for young people to say, ‘This isn’t for me.’”
To create a program that would truly help young people, Ms. Wang and her colleagues decided to focus on young people’s functioning in all domains, not just mental health. The program that resulted was Progressive Adulthood: Skills, Support, Advocacy, Growth, and Empowerment = Success (PASSAGES).
PASSAGES relies on motivational interviewing, peer support, and supported education, employment, and housing to help young people with mental health issues become independent. The program currently serves youth – including Native American youth on reservations – in San Juan and Tooele Counties.
To make sure PASSAGES continues even after SAMHSA’s support ends, the division worked with all the other agencies involved in young adults’ lives to develop a toolkit to guide their work. All staff will undergo training with the toolkit to ensure that they’re all on the same page when it comes to working with young people in transition, said Ms. Wang.
PASSAGES also ensures that young people themselves help design the program, which is where Michelle comes in.
As the program’s youth coordinator, she oversees a youth council and trains young people in transition to be advocates. She plans to maintain that focus as she continues her career. She is now a University of Utah college student who plans to become a social worker and focus on improving policies affecting young adults.
“It’s funny how people create programs for young people without asking youth what they think of them,” said Michelle. “My role is to provide the youth voice and insight and to get other youth involved, too.”
Highlights of the Emerging Adults Initiative
SAMHSA’s Emerging Adults Initiative grantees have used a wide variety of strategies to help reach the program’s goal of helping young people with mental health issues transition into successful adulthood. Here are some highlights:
- Georgia. Providers participating in the state’s Emerging Adults Initiative have partnered with local businesses to provide employment opportunities to young adults as well as volunteer positions, videotaped practice interviews, and job shadowing.
- Maine. The state’s Emerging Adults Initiative has developed a new youth-in-transition policy, and the state itself is putting in place a memorandum of understanding with the state agencies that serve emerging adults.
- Maryland. The state’s Emerging Adults Initiative hosts several problem-solving and decision-making sessions and recreational events for young adults each month.
- Missouri. The state’s Emerging Adults Initiative made policy changes so that individualized services for young adults can be funded based on need rather than age.
- Oklahoma. The state’s Emerging Adults Initiative and Oklahoma Department of Mental Health and Substance Abuse Services created a cross-site data collection instrument to track outcomes for young adults in transition and will use the information gathered to guide policy and practice.
- Utah. The state’s mental health, substance abuse, child welfare, juvenile justice, and disability systems have created a tool-kit to help standardize youth-in-transition services.
- Wisconsin. The state’s Emerging Adults Initiative trains young adult peer specialists who now support other youth in transition.
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