Improving Post-School
Outcomes for Youth
with Mental Health Issues
Mason G. Haber, Ph.D.
Department of Psychology
University of North Carolina at Charlotte
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
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):
–
–
–
–

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“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
Objectives


Today’s talk will focus on research predicting
post-secondary outcomes of youth with MHI &
its implications
Specifically, we will describe:
1) existing research on post-secondary outcomes of
youth with mental health issues (MHIs)
2) research on predictors of outcomes of youth w/MHIs
3) research and best practice guidelines for improving
post-secondary outcomes of youth with MHI
4) policies to improve post-secondary outcomes
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?)
Why Focus on Predicting
Post-secondary Outcomes?
Test et al. (2008). Evidence-based Secondary Transition Practices and Predictors.
Post-secondary Outcomes:
Types and Timing


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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)
Types of Mental Health Issues






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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)
Youth with “Disability” vs.
with “Issues”



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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
Common Challenges


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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)
Post-secondary outcomes
of youth with MHI


Comparisons groups can include ownage 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
Post-secondary outcomes
of youth with MHI
Table 1. Outcomes of Youth with MHI, All Disabilities, &
General Population
Indicator
NLTS1
Youth w/SED
NLTS2, Wave 3 NLTS2, Wave 3 U.S. General
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
Adapted from Clark & Unruh (2009)
What Predicts Outcomes? –
Kohler’s Taxonomy
Student
Development
• Life Skills
• Career & vocational
curriculum
• Structured work
experience
• Assessment
• Support Services
Student
Program
Structure
Student-Focused
Planning
• Philosophy
• IEP development
• Program Policy • Student
• Strategic Plans participation
• Evaluation
• Planning
• Resource
Strategies
Allocation
• Resource
Development
Program/Family
Family
Involvement
• Family Training
• Involvement
• Empowerment
Interagency
Collaboration
• Framework
• Service
Delivery
System
Adapted from Kohler (1996)
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


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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.
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 followup 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 –
NSTTAC meta-analysis



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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
Predictors from
NSTTAC Review

Student Development
predicted 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


Planning predicted education outcomes
Family involvement was only examined in a
study focusing on learning disabled youth

Collaboration
Test et al., (2009).
predicted education outcomes
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 poorer employment
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.
Post-secondary Outcomes of
Youth w/EBD by School Exit Type
Post-secondary Outcomes of Youth
w/EBD by MHSA Service Use
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
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
Family Involvement

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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).
Family & Youth Driven
Wraparound? (Haber, Cook, & Kilmer, 2010)
Caregiver Strain by Age of Youth in Wraparound Services
Caregiver Strain
4
3.5
**
3
2.5
Ages 11-13
Ages 15+
2
** p < .001
1.5
1
0.5
0
Objective
Internalizing
Externalizing
Family & Youth Driven
Wraparound? (Haber, Cook, & Kilmer, 2010)
CFT Processes Among Older vs. Younger Adolescents
4.0000
3.8000
*
Age 11-13
3.6000
Rating
Age 15+
* p < .05
3.4000
3.2000
3.0000
Cohesion youth
Functioning youth
Cohesion caregiver
Measure
Functioning caregiver
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).
Interagency Collaboration


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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)
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

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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
Recommendations for Interagency
Collaboration – State
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Interagency task forces and collaboratives
Learning communities
State-local partnerships (e.g., Healthy Transitions)
Youth summits
– MA, Portland National Summit
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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
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.
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
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
Thank You!!