Improving Post-SchoolImproving Post-School Outcomes for Youth Outcomes for Youth with Mental Health with Mental Health IssuesIssues

Mason G. Haber, Ph.D.Mason G. Haber, Ph.D.

Department of PsychologyDepartment of Psychology

University of North Carolina at University of North Carolina at CharlotteCharlotte

Youth VoicesYouth Voices““For me personally, I had no interest in the typical college experience”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 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 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 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 was always told that if I didn’t walk with my graduation class, I was nothing and would never amount to anything. would never amount to anything.

““It was very helpful to me when my caseworker, my mother, and I all got on the 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 same page. We worked really well together, and this made me feel that we had a good plan”a good plan”

““I needed to be taught to become an adult not when I was 18 but when I was 12,15, 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 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, 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 maintain an account, pay my bills, and clean my apartment. I needed to start learning these skills more than just 2 months before my 18learning these skills more than just 2 months before my 18thth birthday. 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

Understanding Outcomes of Understanding Outcomes of Youth with Mental Health Youth with Mental Health IssuesIssues These youth voices illustrate key predictors of These youth voices illustrate key predictors of

post-school success or failure for youth with post-school success or failure for youth with mental health issues (MHIs):mental health issues (MHIs):– ““Nontypical” learning experiencesNontypical” learning experiences– School completion, both standard and nonstandardSchool completion, both standard and nonstandard– Family involvementFamily involvement– Training in basic skillsTraining in basic skills

Identifying these predictors is the first step Identifying these predictors is the first step toward improving outcomestoward improving outcomes

Data on predictors are a necessary complement Data on predictors are a necessary complement to data on evidence-based practicesto data on evidence-based practices

ObjectivesObjectives

Today’s talk will focus on research predicting Today’s talk will focus on research predicting post-secondary outcomes of youth with MHI post-secondary outcomes of youth with MHI & its implications & its implications

Specifically, we will describe:Specifically, we will describe:1)1) existing research on post-secondary outcomes of existing research on post-secondary outcomes of

youth with mental health issues (MHIs)youth with mental health issues (MHIs)

2)2) research on predictors of outcomes of youth research on predictors of outcomes of youth w/MHIsw/MHIs

3)3) research and best practice guidelines for research and best practice guidelines for improving post-secondary outcomes of youth with improving post-secondary outcomes of youth with MHIMHI

4)4) policies to improve post-secondary outcomespolicies to improve post-secondary outcomes

Why Focus on Predicting Why Focus on Predicting Post-secondary Post-secondary Outcomes?Outcomes? Predictors of in-school success may not Predictors of in-school success may not

translate to post-school gainstranslate to post-school gains Questions to answer:Questions to answer:

– Which Which factorsfactors predictive of in school predictive of in school improvement also result in success post-exit?improvement also result in success post-exit?

– Which Which programs programs or practices impact or practices impact both both in in school and post-school outcomes?school and post-school outcomes?

– Which Which targetstargets for programs (e.g., skills) are for programs (e.g., skills) are most associated with improved post-school most associated with improved post-school outcomes (i.e., outcomes (i.e., mediatorsmediators?)?)

Why Focus on Predicting Why Focus on Predicting Post-secondary Outcomes?Post-secondary Outcomes?

Test et al. (2008). Evidence-based Secondary Transition Practices and

Predictors.

Post-secondary Post-secondary Outcomes:Outcomes:Types and TimingTypes and Timing Measures of employmentMeasures of employment Measures post-secondary educational experiencesMeasures post-secondary educational experiences Combined measures Combined measures (e.g., “productivity” or (e.g., “productivity” or

“engagement”)“engagement”)

Other types of indicatorsOther types of indicators (e.g., independent living, (e.g., independent living, quality of life)quality of life)

Indicator 14 & beyondIndicator 14 & beyond– Transition continues past post-exit year 1, so these Transition continues past post-exit year 1, so these

“outcomes” are predictors as well“outcomes” are predictors as well Outcomes are also linkedOutcomes are also linked (e.g., employment may drive (e.g., employment may drive

or inhibit education)or inhibit education)

Types of Mental Health Types of Mental Health IssuesIssues

Pervasive dysregulation (i.e., SED/EBD)Pervasive dysregulation (i.e., SED/EBD) Clinically significant depression or anxietyClinically significant depression or anxiety Severe or complex traumatization Severe or complex traumatization Delinquent/illegal behavior, including Delinquent/illegal behavior, including

substance use/abusesubstance use/abuse Dual diagnoses, including other Dual diagnoses, including other

disabilities (e.g., ID, LD)disabilities (e.g., ID, LD) Adjustment issuesAdjustment issues Emerging or prodromal psychotic disorderEmerging or prodromal psychotic disorder

Synthesis Inc. (2006; 2009)

Youth with “Disability” Youth with “Disability” vs.vs.with “Issues”with “Issues” For MHIs, the disability label may be particularly For MHIs, the disability label may be particularly

stigmatizing stigmatizing (Clark & Davis, 2000)(Clark & Davis, 2000)

Disability label may not be a fit; even “severe” Disability label may not be a fit; even “severe” issues may not be lifelong issues may not be lifelong (Burt & Masten, 2010)(Burt & Masten, 2010)

Focusing on MHIs is inclusive of youth who could Focusing on MHIs is inclusive of youth who could

benefit from secondary prevention benefit from secondary prevention – e.g., as part of a comprehensive school-based e.g., as part of a comprehensive school-based

mental health planmental health plan (Simonsen & Sugai, 2009)(Simonsen & Sugai, 2009)

Although our focus Although our focus today is on youth classified today is on youth classified as disabled, a wider continuum should be as disabled, a wider continuum should be addressedaddressed

Common ChallengesCommon Challenges

Developmental TransitionsDevelopmental Transitions Institutional TransitionsInstitutional Transitions These transitions may be particularly These transitions may be particularly

problematic for youth w/MHIproblematic for youth w/MHI ““Unique” factorsUnique” factors

– Disability reflects meta-cognitive deficitsDisability reflects meta-cognitive deficits– Strain on relationships w/adultsStrain on relationships w/adults– ““Invisibility” of disabilityInvisibility” of disability– All of these impact post-secondary outcomesAll of these impact post-secondary outcomes

Davis, Green, & Hoffman (2009); Davis & Vander Stoep (1997); Podmostko (2007)

Post-secondary Post-secondary outcomes of youth outcomes of youth with MHIwith MHI Comparisons groups can include own-Comparisons groups can include own-

age peers or youth w/other disabilitiesage peers or youth w/other disabilities Youth w/MHI vs. other disabilities haveYouth w/MHI vs. other disabilities have

– Poorer employment outcomesPoorer employment outcomes– Lower % of secondary school completion Lower % of secondary school completion – Lower % in post-secondary educationLower % in post-secondary education– Much Much higher rates of negative outcomeshigher rates of negative outcomes

e.g., criminal justice, drug use, pregnancye.g., criminal justice, drug use, pregnancy

Post-secondary Post-secondary outcomes of youth outcomes of youth with MHIwith MHI

Table 1. Outcomes of Youth with MHI, All Disabilities, & General Population

Adapted from Clark & Unruh (2009)

NLTS1 NLTS2, Wave 3 NLTS2, Wave 3 U.S. General Indicator Youth w/SED Youth w/EBD All Population

H.S.school completion 48 62 79 79

Currently employed 48 42 55 62

Post-secondary education 26 31 42 49

Living with family 45 66 73 65

What Predicts Outcomes? What Predicts Outcomes? – Kohler’s Taxonomy– Kohler’s Taxonomy

Student

Program/Family

System

Student Program Student-Focused Family InteragencyDevelopment Structure Planning Involvement Collaboration

• Life Skills • Philosophy • IEP development • Family Training • Framework• Career & vocational • Program Policy • Student • Involvement • Service curriculum • Strategic Plans participation • Empowerment Delivery• Structured work • Evaluation • Planning experience • Resource Strategies• Assessment Allocation• Support Services • Resource

Development

Adapted from Kohler (1996)

Predictors of Outcomes Predictors of Outcomes – – NSTTAC meta-analysisNSTTAC meta-analysis Test et al. (2009) reviewed studies on predictors Test et al. (2009) reviewed studies on predictors

of post-secondary outcomes for all youth of post-secondary outcomes for all youth w/disabilitiesw/disabilities– Three outcomes: Three outcomes: EmploymentEmployment, , Post-secondary Post-secondary

EducationEducation, & , & Independent LivingIndependent Living Studies were coded by Kohler taxonomy categoryStudies were coded by Kohler taxonomy category Coding has just been completed for a meta-Coding has just been completed for a meta-

analysis and extension of this study (analysis and extension of this study (N N = 36 = 36 studies)studies)

What has been found in the studies focusing on What has been found in the studies focusing on youth w/ MHI?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.

Predictors of Outcomes – Predictors of Outcomes – NSTTAC meta-analysis NSTTAC meta-analysis

2 studies!!2 studies!! Study 1: A secondary analysis of NLTS-Study 1: A secondary analysis of NLTS-

11 (Rylance, 1998)(Rylance, 1998)

– Predictors of Predictors of employmentemployment: “Functional : “Functional competence”; H.S. Diploma achievement (~10% of competence”; H.S. Diploma achievement (~10% of variance)variance)

– Vocational & counseling predicted only 2.54% Vocational & counseling predicted only 2.54%

Study 2:“Steps to Success” Study 2:“Steps to Success” (Karpur et al., (Karpur et al., 2005)2005)

– Participants later showed greater Participants later showed greater post-secondary post-secondary enrollmentenrollment than matched youth than matched youthKarpur 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

Predictors of Outcomes – Predictors of Outcomes – NSTTAC meta-analysisNSTTAC meta-analysis

NN=20 studies had significant #s of youth w/ =20 studies had significant #s of youth w/ MHI (> 5%) or included all disabilitiesMHI (> 5%) or included all disabilities

Significant predictors were identified in all 5 Significant predictors were identified in all 5 Kohler taxonomy categoriesKohler taxonomy categories

By far, By far, student developmentstudent development and and program program structurestructure were best represented were best represented

Fewer studies focused on Fewer studies focused on planningplanning, , family family involvementinvolvement, and , and coordinationcoordination

Note that the former categories are program Note that the former categories are program level factors, the latter, system-levellevel factors, the latter, system-level

Predictors from Predictors from NSTTAC ReviewNSTTAC Review Student DevelopmentStudent Development predicted 3 outcomes predicted 3 outcomes

(education, employment, and independent living)(education, employment, and independent living) – Examples: career awareness, community experiences, Examples: career awareness, community experiences,

diploma receipt, self-determinationdiploma receipt, self-determination

Program structureProgram structure (e.g., specialized transition (e.g., specialized transition programs) predicted education & employment programs) predicted education & employment outcomesoutcomes

PlanningPlanning predicted education outcomespredicted education outcomes

Family involvementFamily involvement was only examined in a was only examined in a study focusing on learning disabled youthstudy focusing on learning disabled youth

CollaborationCollaboration predicted education outcomespredicted education outcomes

Test et al., (2009).

Findings from Scientific Findings from Scientific Proceedings Proceedings (Karpur, Haber, & Clark, 2007)(Karpur, Haber, & Clark, 2007)

Karpur et al. (2007)Karpur et al. (2007) linked Florida DOE linked Florida DOE databases to predict outcomes 2 years post-exitdatabases to predict outcomes 2 years post-exit – Youth w/MHIs analyzed separatelyYouth w/MHIs analyzed separately– Predictors: diploma type & service utilizationPredictors: diploma type & service utilization

Findings:Findings:– Certificates & nonstandard diplomas improved Certificates & nonstandard diplomas improved

employment and education outcomesemployment and education outcomes– MHSA service utilization related to MHSA service utilization related to poorerpoorer

employment and education outcomes employment and education outcomes – Note, despite propensity scoring use to balance Note, despite propensity scoring use to balance

groups, MHSA youth may have more severe problemsgroups, 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.

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

TypeType

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

UseUse

Research on Research on predictors:predictors:ImplicationsImplications Youth w/MHI have poorer outcomes than youth Youth w/MHI have poorer outcomes than youth

w/disabilities overallw/disabilities overall Student developmentStudent development predicts outcomes predicts outcomes

– Functional competence Functional competence & & diploma achievement diploma achievement (both standard & nonstandard) (both standard & nonstandard) (e.g., Karpur et al., (e.g., Karpur et al., ’05, ’07; Rylance, 1998)’05, ’07; Rylance, 1998)

Programs Programs focusing on transition issues (e.g., focusing on transition issues (e.g., steps to success) predict better outcomessteps to success) predict better outcomes– Bridges to Work, TIP , RENEWBridges to Work, TIP , RENEW

General vocational services, counseling, and General vocational services, counseling, and MHSA predict weakly, at best MHSA predict weakly, at best

Research on Research on Predictors:Predictors:ImplicationsImplications More research and evaluation of More research and evaluation of planningplanning, , family family

involvementinvolvement, & , & interagency collaborationinteragency collaboration are are needed.needed.

Despite the lack of post-school outcome data, Despite the lack of post-school outcome data, other types of evidence suggest these are other types of evidence suggest these are promising areas of focus, including:promising areas of focus, including:– Data on role of family support among students in Data on role of family support among students in

general, and also normal & vulnerable young adults general, and also normal & vulnerable young adults – Data on wraparound and systems of careData on wraparound and systems of care– Evidence-based practices w/similar populationsEvidence-based practices w/similar populations– Best practice guidelines & promising program Best practice guidelines & promising program

modelsmodels

Family InvolvementFamily Involvement

Parent involvement relates to better Parent involvement relates to better performance on student & school levelsperformance on student & school levels

Research on young adults suggests financial Research on young adults suggests financial independence is not achieved until 25 or laterindependence is not achieved until 25 or later

Involvement by parents and other supportive Involvement by parents and other supportive adults also critical for youth w/MHI specificallyadults also critical for youth w/MHI specifically

HoweverHowever, the role of family changes, and , the role of family changes, and working with families may become more working with families may become more challengingchallenging– This has important implications for planning and This has important implications for planning and

interagency coordinationinteragency coordinationSelected References: Haber, Cook, & Kilmer (2010); Hatter, Williford, & Dickens; Jivanjee, P., Kruzich, J.M., & Gordon, L.J. (2009).

Family & Youth Driven Family & Youth Driven Wraparound? Wraparound? (Haber, Cook, & Kilmer, (Haber, Cook, & Kilmer,

2010)2010)

Caregiver Strain

0

0.5

1

1.5

2

2.5

3

3.5

4

Objective Internalizing Externalizing

Ages 11-13

Ages 15+

**

** p < .001

Caregiver Strain by Age of Youth in Wraparound Services

Family & Youth Driven Family & Youth Driven Wraparound? Wraparound? (Haber, Cook, & Kilmer, (Haber, Cook, & Kilmer,

2010)2010)

3.0000

3.2000

3.4000

3.6000

3.8000

4.0000

Cohesion - youth

Functioning -youth

Cohesion -caregiver

Functioning -caregiver

Measure

Ra

tin

g

Age 11-13

Age 15+

*

* p < .05

CFT Processes Among Older vs. Younger Adolescents

Solutions? Solutions?

In a recent review of wraparound child & family In a recent review of wraparound child & family teams (CFTs) for a local transition program:teams (CFTs) for a local transition program:– Intact CFTs performed poorlyIntact CFTs performed poorly– Youth-identified CFTs were more dynamicYouth-identified CFTs were more dynamic– The best teams formed to respond to a The best teams formed to respond to a futures futures

plan plan created by youth with transition specialists. created by youth with transition specialists. – In some cases, teams met only sporadically, had In some cases, teams met only sporadically, had

changing membership, or were not used.changing membership, or were not used.– In sum: team development proceeded best when In sum: team development proceeded best when

tailored to youth driven planstailored to youth driven plans

D. Jackson-Diop (personal communication, May 17th ,2010).

Interagency Interagency CollaborationCollaboration Needs for interagency collaboration to support Needs for interagency collaboration to support

developmental transition of youth are cleardevelopmental transition of youth are clear In transitioning to adulthood, youth experience In transitioning to adulthood, youth experience

many changes at once and have diverse needsmany changes at once and have diverse needs Institutional transitions/silos can also be disruptiveInstitutional transitions/silos can also be disruptive Well documented examples for youth w/MHI:Well documented examples for youth w/MHI:

– The siloing of child and adult mental health systemThe siloing of child and adult mental health system– Siloing of mental health and substance abuse services is Siloing of mental health and substance abuse services is

problematic due to high rates of co-occurring disordersproblematic due to high rates of co-occurring disorders Reviews, expert opinion surveys, & case studies Reviews, expert opinion surveys, & case studies

provide insights on improving collaboration provide insights on improving collaboration (e.g., (e.g., Haber et al., 2007; Davis et al., 2009)Haber et al., 2007; Davis et al., 2009)

Recommendations for Recommendations for Interagency Collaboration – Interagency Collaboration – LocalLocal Placing personnel from other sectors in Placing personnel from other sectors in

schools, starting from early onschools, starting from early on– VR, adult mental health, transition VR, adult mental health, transition

specialists, community college counselors, specialists, community college counselors, benefits counselorsbenefits counselors

Transition case review teamsTransition case review teams Community Steering CommitteesCommunity Steering Committees

– Youth voice and leadership are importantYouth voice and leadership are important Mechanisms for blending fundingMechanisms for blending fundingSources: 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

Recommendations for Recommendations for Interagency Collaboration – Interagency Collaboration – StateState Interagency task forces and collaborativesInteragency task forces and collaboratives Learning communitiesLearning communities State-local partnerships (e.g., Healthy State-local partnerships (e.g., Healthy

Transitions)Transitions) Youth summitsYouth summits

– MA, Portland National SummitMA, Portland National Summit

Policies to address service silosPolicies to address service silos (e.g., flexible (e.g., flexible reimbursement, addressing inconsistencies in eligibility reimbursement, addressing inconsistencies in eligibility criteria) criteria)

Technical Assistance to localities to use data Technical Assistance to localities to use data more effectivelymore effectively (e.g., longitudinal data systems)(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

Collaborative Program Collaborative Program & System Models& System Models Transition to Independence Process Transition to Independence Process

(TIP)(TIP) (Clark, 1995, 2004)(Clark, 1995, 2004)

Rehabilitation, Empowerment, Natural Rehabilitation, Empowerment, Natural Supports, Education, and WorkSupports, Education, and Work (RENEW; (RENEW; Malloy, Drake, & Couture, 2009)Malloy, Drake, & Couture, 2009)

– Both of these models were specifically Both of these models were specifically developed for youth with MHIdeveloped for youth with MHI

– RENEWRENEW provides guidelines for use within a provides guidelines for use within a School-wide Positive Behavioral Support School-wide Positive Behavioral Support ProgramProgramClark, 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.

ConclusionsConclusions

Research on post-school outcomes identifies Research on post-school outcomes identifies important important factorsfactors, , programsprograms, and , and targetstargets related to post-school successrelated to post-school success

Schools and communities can:Schools and communities can:– Evaluate programs by measuring in-school factors and Evaluate programs by measuring in-school factors and

targets related to post-school successtargets related to post-school success– Use promising specialized transition programs such as Use promising specialized transition programs such as

TIP and RENEW, as part of a school-based mental TIP and RENEW, as part of a school-based mental health continuum of carehealth continuum of care

– Attend to Attend to developmentally appropriate developmentally appropriate family family involvement and care coordination, using models such involvement and care coordination, using models such as TIP & RENEW to guide these strategiesas TIP & RENEW to guide these strategies

ConclusionsConclusions

States can assist schools & communities by:States can assist schools & communities by:– Providing technical assistance in measurement of in Providing technical assistance in measurement of in

school variables most strongly related to outcomes school variables most strongly related to outcomes – Promote dissemination of promising transition Promote dissemination of promising transition

programs (e.g., by working with purveyors to programs (e.g., by working with purveyors to provide centralized technical assistance)provide centralized technical assistance)

– Invest in longitudinal data systems to improve Invest in longitudinal data systems to improve evidence-base on post-school outcomes and inform evidence-base on post-school outcomes and inform local effortslocal efforts

– Develop policies that address child & adult mental Develop policies that address child & adult mental health as well as other service siloshealth as well as other service silos

– Create post-school outcome focused statewide plansCreate post-school outcome focused statewide plans

Thank You!!