1. Effective Behavioral Health Programming for Transition-Age Youth
Image: Young male, arms on knees, covering his face.
Effective Behavioral Health Programming for Transition-Age Youth
The views, opinions, and content of this presentation are those of the presenters and do not necessarily reflect the views, opinions, or policies of SAMHSA or the U.S. Department of Health and Human Services.
Charles E. Lewis, Jr., Ph.D., Facilitator
Minority Fellowship Program Coordinating Center

2. Presenters Charles E Lewis, Jr., PhD, MSW Hewitt B. “Rusty” Clark, PhD
Principal Associate and Training Director for the Development Services Group (DSG) Minority Fellowship Program Coordinating Center (MFPCC); former CSWE MFP Fellow, Columbia University 2000–01.
Hewitt B. “Rusty” Clark, PhD
Director of the National Network on Youth Transition for Behavioral Health (NNYT); Professor Emeritus at the Department of Child & Family Studies, Florida Mental Health Institute, College of Behavioral and Community Sciences, University of South Florida.
Gloria Reeves, MD
Director of Maryland’s Strive for Wellness program and an Associate Professor in the Department of Psychiatry at the University of Maryland.

3. Transition-Age Youth
This Webinar will focus on the behavioral health needs of youth and young adults between the ages of 16 and 25 years who are transitioning into adulthood. Some are living at home with parents, aging out of foster care, and may or may not be working or in school. Transition-age youth are particularly at risk for first episodes of mental illness and substance abuse.

4. Transition-Age Youth
Image: Group of young people representing transition-age youth, 16–24 years old.
There are 38.6 million noninstitutionalized individuals in the U.S. between the ages of 16 and 24 years1
This represents about 15 percent of the U.S. population
12.7 million (33 percent) were enrolled in school
20.3 million (52.7 percent) were working
1U.S. Bureau of Labor Statistics

5. Transition Age Youth
The years of transitioning from adolescence to adulthood have challenges
Particularly for youth aging out of foster care or leaving the juvenile justice system
As they move into the adult system, they are covered by new laws and regulations
This transition poses enormous hurdles for youth with behavioral health problems

6. Disconnected Youth
Estimated 6.5 million disconnected youth—out of school and out of work—ages 16–24 in the United States in
Image: Chart with percentages and numbers of 16 to 24 year olds out of school and out of work
1Annie E. Casey Foundation “Youth and Work” Report

7. Aging Out of Foster Care
According to HHS, about 500,000 children are in foster care on a given day
About 26,000 “age out” each year
Most states set 18 years old as the beginning of adulthood, however many states extend foster care until 21 years under certain circumstances (being enrolled in school)
Image: Young male student, foreground; group of students in background.

8. Aging Out of Foster Care
At the age of 24, only half are employed1
More than one in 5 will become homeless after age 18
Only 58 percent will graduate high school by age 19 (compared to 87 percent of all 19 year olds)
Fewer than 3 percent will earn a college degree by age 25 (compared to 28 percent of all 25 year olds)
One in four will be involved in the criminal justice system within two years of leaving foster care
1Annie E. Casey Foundation

9. Transition-Age Youth
According a 2012 Mathematica study (using 2009 data):
About 6.3 percent of transition-age youth have a disability (about 2.5 million).
The incidence of disability for the 500,000 youth in institutional settings is about 24 percent.
Research shows that transition-age youth with mental health problems compared to those without are less likely to finish high school, less likely to be employed, more likely to become pregnant, and more likely to be involved in criminal activity.

10. Transition-Age Youth
The most common primary diagnosis among transition age youth is depression (21.6 percent), followed by bipolar (14.6 percent), disruptive (14.2 percent), and anxiety (12.9 percent) disorders
Image: Young female holding her head.
Comorbidity is common, with approximately 60 percent of those with a disability having more than one diagnosis, 41.0 percent having a co-occurring medical problem, and 20.3 percent a substance use problem

11. Transition-Age Youth
Some adolescents enter the transition-age period with pre- existing mental health problems and have received services from child-serving systems, while others do not develop mental health problems until the transition period and thus have no prior service system involvement.
Adult systems often focus exclusively on providing services for the needs of persons with serious and persistent mental illnesses. Thus, the expertise of clinical personnel and ancillary services offered in adult systems may not be well matched to the clinical profiles of transition-age youth.

12. Federal Laws/Programs
The Child Abuse Prevention and Treatment Act (CAPTA)
Signed into law in 1974
Reauthorized in 1978, 1984, 1988, 1992, 1996, and 2003
Funds states to prevent and address child abuse
The Adoptions and Safe Families Act of 1997
Made the well-being of children paramount to the rights of biological parents
Aimed to increase the number of children in foster care placed in permanent homes

13. Federal Laws/Programs
The Comprehensive Community Mental Health Services for Children and Their Families Program
Launched by SAMHSA’s Center for Mental Health Services (CMHS) in 1992, the program promotes a coordinated, community-based approach to care for children and adolescents with serious mental health challenges and their families (Systems of Care)
The Foster Care Independence Act of 1999
Established the John H. Chafee Foster Care Independence Program (CFCIP)
Required ACF to develop a data collection/tracking system

14. Federal Laws/Programs
Fostering Connections to Success and Increasing Adoptions Act of 2008
Created an option for state and tribal agencies to provide kinship guardianship assistance payments
Patient Protection and Affordable Care Act
Extended Medicaid coverage to former foster care children younger than age 26
Eligible for benefits from the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) provisions of Medicaid until age 21

15. Now Is The Time (NITT)
Substance Abuse and Mental Health Services Administration (SAMHSA) created two programs to address the behavioral health needs of transition age youth:
Now Is The Time MFP—Addiction Counselors
Now Is The Time MFP—Youth
Train master’s level practitioners to work with transition age youth in unserved and underserved communities

16. Transition to Independence Process
Transition-Age Youth
Today’s Webinar will focus on a successful program designed to move transition-age youth with behavioral health problems into independence
Transition to Independence Process
The Webinar will also examine best practices for the use of psychotropic medications with transition-age youth
Image: Various pills and capsules spread across a tabletop.

17. Hewitt “Rusty” Clark Ph.D., BCBA
Image: Lighthouse atop rocky ledge above water
Navigating Rough Waters: TIP Model™: Improving Outcomes for Youth and Young Adults with EBD
Hewitt “Rusty” Clark Ph.D., BCBA
© Copyright 2012– All rights reserved – Stars Behavioral Health Group

18. SBHG / NNYT Mission To improve the progress and outcomes for:
Youth and young adults (14–29 years of age) with emotional/behavioral difficulties (EBD)
Through system development, program implementation, research, and dissemination in collaboration with provider agencies, communities, states, and national/federal entities.
© Copyright 2012– All rights reserved – Stars Behavioral Health Group

19. Comparison of Transition Domains Between the General Population and Young People (YP) with EBD
Blackorby J., Wagner M. Longitudinal postschool outcomes of youth with disabilities: Findings from the National Longitudinal Transition Study. Except Child 1996; 62:
Clark, H.B. & Davis, M. (Eds.) (2000): Transition to adulthood: A resource for assisting young people with emotional or behavioral difficulties. Baltimore: Brookes Publishing.
Karpur, A., Clark, H.B., Caproni, P., & Sterner, H. (2005).  Transition to adult roles for students with emotional/behavioral disturbances:  A follow-up study of student exiters from a transition program. Career Development for Exceptional Individuals, 28(1),
Vander Stoep, A., Davis, M., & Collins, D. (2000). Transition: A time of developmental and institutional clashes. In H.B.Clark & M. Davis (Eds.) Transition of Youth and Young Adults with Emotional/Behavioral Disturbances in Adulthood: Recommended Practices, Research Findings and Policy Implications (pp. 3-28). Baltimore, MD: Brookes Publishing Company.
Vander Stoep, A., Beresford, S.A.A., Weiss, N.S., McKnight, B., Cauce, A. M., &
Cohen, P. (2000). Community-based study of transition to adulthood for adolescents with psychiatric disorders. American Journal of Epidemiology, 152,
© Copyright 2012– All rights reserved – Stars Behavioral Health Group

20. Likelihood of Youth With EBD Being Incarcerated
Prange, M. (1993). A longitudinal perspective of youth with conduct disorder problems. Paper presented at the Rehabilitation of Children, Youth, and Adults with Psychiatric Disabilities Conference, Tampa, FL. Waves 1-7; N=497
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21. Barriers Youth and Young Adult Level Family Level
Community/ System Level
Image: Three individuals climbing rocks.
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Image: Cartoon with two prehistoric men.
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23. Transition to Independence Process TIP Model
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24. What is the TIP Model™?
Transition to Independence Process (TIP) system:
Engage youth and young adults (14–29 years old) in their own futures planning process.
Provide them with developmentally appropriate services and supports.
Involve them and their families and other informal key players.
In a process that prepares and facilitates them in their movement toward
Greater self-sufficiency
Successful achievement of their goals
© Copyright 2012– All rights reserved – Stars Behavioral Health Group

25. TIP Model™ Guidelines Practice Level Program Level
Young Person
Informal Key Players (e.g., family members, friends)
Formal Key Players (e.g., therapist, teacher, probation officer)
Program Level
Community System Level
State and Federal Policy Level
The TIP Model Guidelines
At the practice level, these guide the Transition Facilitator’s moment to moment, day to day, week to week work with a young person (and those around him or her).
The extent to which the program, community system, and policy levels are aligned with these guidelines, the more seamless and effective the transition program.
© Copyright 2012– All rights reserved – Stars Behavioral Health Group

26. TIP Model™ Guidelines
Engage young people through relationship development, person-centered planning, and a focus on their futures.
Tailor services and supports to be accessible, coordinated, appealing, nonstigmatizing, and developmentally appropriate—building on strengths to enable the young people to pursue their goals across relevant transition domains.
Engage young people through relationship development, person-centered planning, and a focus on their futures.
2. Tailor services and supports to be accessible, coordinated, appealing, non-stigmatizing, and developmentally-appropriate -- building on strengths to enable the young people to pursue their goals across relevant transition domains.
3. Acknowledge and develop personal choice and social responsibility with young people.
Background Image: Young people seated
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27. Educational Opportunity Personal Effectiveness & Well-Being
Transition Domains
Employment & Career
Living Situation
Educational Opportunity
Community
Life
Functioning
Personal Effectiveness & Well-Being
Talk about how impairments occur in each domain May elaborate briefly on each with examples
This domain graph is good to show YP because they are visual
It maps for them what they need to focus on and what to do to take independence to next level
© Copyright 2012– All rights reserved – Stars Behavioral Health Group

28. Transition Domains: Subdomains
Personal Effectiveness and Well-Being
Interpersonal Relationships
Emotional and Behavioral Well-Being
Self-Determination
Communications
Physical Health and Well-Being
Parenting
Community-Life Functioning
Daily Living Skills
Leisure Activities
Community Participation
© Copyright 2012– All rights reserved – Stars Behavioral Health Group

29. TIP Model™ Guidelines
Acknowledge and develop personal choice and social responsibility with young people.
Ensure a safety net of support by involving a young person’s parents, family members, and other informal and formal key players.
Engage young people through relationship development, person-centered planning, and a focus on their futures.
2. Tailor services and supports to be accessible, coordinated, appealing, non-stigmatizing, and developmentally-appropriate -- building on strengths to enable the young people to pursue their goals across relevant transition domains.
3. Acknowledge and develop personal choice and social responsibility with young people.
Background Image: Young people seated
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30. Futures Planning with YP: Planning Partners and Necessary Connections
Planning partners are selected by YP.
YP might choose different key players to serve as planning partners for different topics, needs, or goals.
Often a YP may want to only involve him/herself and one or two key players (e.g., transition facilitator, parent, friend) to serve as planning partner(s).
NOTE: With older youth and young adults, typically over 95 percent of the planning meetings are with just the YP and TF.
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31. Futures Planning with YP: Planning Partners and Necessary Connections
YP’s topic/need/goal determines who is a necessary connection(s) (e.g., probation officer, vocational rehabilitation counselor, community college instructor) for him/her to make progress on this topic, need, or goal.
YP and transition facilitator or other planning partner would contact, plan, and/or negotiate with necessary connection(s) regarding a particular topic, need, or goal.
© Copyright 2012– All rights reserved – Stars Behavioral Health Group

32. TIP Model™ Guidelines
Enhance young persons’ competencies to assist them in achieving greater self-sufficiency and confidence.
Engage young people through relationship development, person-centered planning, and a focus on their futures.
Tailor services and supports to be accessible, coordinated, appealing, non-stigmatizing, and developmentally-appropriate -- building on strengths to enable the young people to pursue their goals across relevant transition domains.
Acknowledge and develop personal choice and social responsibility with young people.
Background Image: Young people seated
© Copyright 2012– All rights reserved – Stars Behavioral Health Group

33. TIP Model™ Core Practices
Strength Discovery and Needs Assessment
Futures Planning
Rationales
In-vivo Teaching
Problem Solving (SODAS)
Prevention Planning Process on High Risk Behaviors
Mediation with Young People and Other Key Players

34. TIP Model™ Guidelines
Maintain an outcome focus in the TIP system at the young person, program, and community levels.
Engage young people through relationship development, person-centered planning, and a focus on their futures.
Tailor services and supports to be accessible, coordinated, appealing, non-stigmatizing, and developmentally-appropriate -- building on strengths to enable the young people to pursue their goals across relevant transition domains.
Acknowledge and develop personal choice and social responsibility with young people.
Background Image: Young people seated
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35. Research on the TIP Model: Progress and Outcome Studies
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36. TIP Model Implementation and Progress/Outcomes Evaluation of Progress and Outcomes for Youth and Young Adults at a New TIP Model Implementation Site
Presenter:
If any questions regarding this TIP model / TAS team initial evaluation, please contact Kelly France or Hewitt B. “Rusty” Clark
© Copyright 2012– All rights reserved – Stars Behavioral Health Group

37. TIP Model Implementation Progress and Outcome Indicators on Young People
Initial Implementation of TIP model in Muskegon County, Mich.
Transition Age Services (TAS) team is the lead TIP model entity
Building community collaborative across mental health, family court, probation, homeless/runaway, and child welfare: Muskegon County TIP Model Collaborative
TIP Community Steering Committee
Presenter: Some this information may be more than you need based on the goal of your presentation and your audience.
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38. TIP Model Implementation Progress and Outcome Indicators on Young People
First 12 months of TIP model supports and services
TAS Transition Facilitators (TFs) working with 29 youth and young adults over first 12 months.
Main referrals from court, juvenile justice, and probation. Age of YP: 14–26 years old.
YP have serious mental health conditions (SMHC) and at risk of, or extensive histories of, out of home placements, co-occurring substance use (e.g., cannabis dependence, polysubstance dependence), developmental trauma, and/or multiple-system involvement.
Presenter: Some this information may be more than you need based on the goal of your presentation and your audience.
© Copyright 2012– All rights reserved – Stars Behavioral Health Group

39. TIP Model Implementation: New Site Findings
Community Life and Living Situation Progress Indicators
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40. TIP Model Implementation: New Site Findings
Education and Employment Progress Indicators
Presenter: A note of clarification. Regarding the fourth set of bars “Graduated HS / GED”, three of the 29 participants had graduated prior to entering the Transition Age Service (TAS) Team TIP model services.

41. Research Findings on the TIP Model
Numerous published studies that demonstrate improvement in real-life outcomes for youth and young adults with EBD.
Refer to Theory and Research section of the TIP model website.
National Network on Youth Transition

42. TIP Model™ Guidelines
Involve young people, parents, and other community partners in the TIP system at the practice, program, and community levels.
Engage young people through relationship development, person-centered planning, and a focus on their futures.
Tailor services and supports to be accessible, coordinated, appealing, non-stigmatizing, and developmentally-appropriate -- building on strengths to enable the young people to pursue their goals across relevant transition domains.
Acknowledge and develop personal choice and social responsibility with young people.
Background Image: Young people seated
© Copyright 2012– All rights reserved – Stars Behavioral Health Group

43. TIP Model™ Guidelines
Maximize the involvement of young people, family members, informal and formal key players, and other community representatives.
Tap the talents of peers and mentors:
Hire young adults as peer associates (possible functions such as mentoring, counseling, and/or leadership development).
Assist young people in creating peer support groups and youth leadership opportunities.
© Copyright 2012– All rights reserved – Stars Behavioral Health Group

44. TIP Model™ Guidelines
Use paid and unpaid mentors (e.g., co-worker mentors, college mentors, apartment roommate mentors).
Partner with young people, parents, and others in the TIP system governance and stewardship.
Advocate for system development, expansion, and evaluation—and for reform of funding and policy to facilitate implementation of responsive, effective community transition systems for youth and young adults and their families.
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45. Developmental Markers: Rights of Passage into Adulthood
Completing schooling and training
Developing a social network
Obtaining/maintaining rewarding employment/career
Image: Man and woman in coffee shop.
Becoming financially self- supporting
Participating in your community and being a good citizen
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Image: Young man holding plaque.

46. Implementation Sustainability
TIP Model™
Implementation
Sustainability
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47. TIP Training and Implementation Steps
TIP Model™
Implementation
Site Readiness Assessment
Sustaining TIP
Implementation
Agency
Commitment/
Selection
Technical
Assistance
Calls
Planning and
Preparation
On-Site
Training and Consultation
TIP Cross-Site
Forum
© Copyright 2012– All rights reserved – Stars Behavioral Health Group

48. TIP Model Implementation
Improve progress and outcomes for transition-age young people (14–29 years of age) with EBD
Implementation in collaboration with a provider agency, community collaboratives, counties, and states
© Copyright 2012– All rights reserved – Stars Behavioral Health Group

49. SBHG Stars Training Academy
Serves as the Purveyor of the
Transition to Independence Process (TIP) model
Guided by Implementation Science
Community and rural areas in over 25 states and regions across North America are implementing this evidence-supported practice.
© Copyright 2012– All rights reserved – Stars Behavioral Health Group

50. Focus on Implementation
Training and field-based supports for personnel – front-line and supervisory
TIP Solutions Review process
Supervisors mentored in coaching
Strong youth and young adult voice
YP, family, and partners in governance
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51. From Day 1 An Eye Toward Sustainability
Building site capacity
For example, Site-Based Trainers
Local Fidelity QI Assessors
Expanding community partnerships
Building a TIP Model Community of Practice
Access for housing or college
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52. Meaningful Evaluation Systems
YP satisfaction with helpfulness services
Progress and outcome indicators
YP level
Program aggregate data
TIP Model Quality Improvement Fidelity
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53. Sustainability of your site is facilitated by
Youth and Young Adult Voice
Image: Mixed-race group of young people.
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54. Hewitt B. “Rusty” Clark, Ph.D.,
The Transition Handbook
Transition of Youth and Young Adults with Emotional or Behavioral Difficulties: An Evidence-Supported Handbook
Hewitt B. “Rusty” Clark, Ph.D.,
and Deanne K. Unruh, Ph.D.
Brookes Publishing, 2009
© Copyright 2012– All rights reserved – Stars Behavioral Health Group

55. Hewitt B. “Rusty” Clark, Ph.D., BCBA
If your organization is interested in implementation of the TIP model please contact us:
Hewitt B. “Rusty” Clark, Ph.D., BCBA
Joseph Solomita, MSW
© Copyright 2012– All rights reserved – Stars Behavioral Health Group

56. Principles of Safe and Effective Medication Treatment of Transition-Age Youth/Young Adults
Gloria Reeves MD
Associate Professor
Division of Child and Adolescent Psychiatry
University of Maryland, School of Medicine

57. Objectives
Introduce general principles/strategies to support safe and effective medication treatment
Discuss two examples of commonly prescribed medications (stimulant medications, antipsychotic medications)
Introduce a resource for youth with early signs of serious mental illness

58. Principle #1
A comprehensive evaluation is needed to develop a safe and effective treatment plan
Image: Comprehensive evaluation diagram.

59. Strategies: Evaluation
Multiple sources of information: parent/family, school/work
Assess timeline/context of symptoms
Screen for developmental high risk behaviors
Assess physical health
Image: Stethoscope with red heart ornament.

60. Principle #2
Use informed consent process as an opportunity to teach about treatment decision-making
Image: Consent form.

61. Strategy Identify patient priorities/expectations/values for treatment
Help generate questions about medication and other treatment options
Discuss pros and cons of treatments
Support opportunities to seek additional info and consultation (e.g., trusted family advisor, consumer support program, accurate websites)
Establish opportunities to revisit decisions

62. Prescribing Principle #3
Have a plan to track for medication benefits and side effects
Image: Bottles of psychotropic medications.

63. Strategies: Outcomes-based Care
Assess baseline symptom severity and frequency at baseline
Use observer rating scales to assess behavioral concerns and self report for internalizing symptoms (e.g., anxiety)
Assess side effect issues at baseline (e.g., obtain baseline labs and weight/height)
Optimize treatment to achieve recovery/remission

64. Prescribing Principle #4
Monitor adherence at each medication follow-up visit
Image: Pill dispenser for medications.

65. Strategies: Universal Adherence Monitoring
Assess adherence at each medication visit
Adherence may change over development (e.g. teenagers want to become independent)
Free apps and other tools may be helpful
Anticipate adherence concerns for complex regimens as well as complex family situations (e.g. child lives between 2 households)
Reinforce accurate reporting, not “compliance” with medication

66. Building self-reliance for adherence
Smart Phone Apps (free)
iPhone and Android
MyMedSchedule
MyMeds
MedSimple
PillManager
Mymedschedule.com

67. Principle #5
All psychiatric treatment should involve universal screening for trauma
Image: Checklist with hand holding red pencil.

68. Strategy: Assess Common Concerns
The ACE Study, 1995–97
17,000 adults undergoing a standardized physical
through Kaiser Permanente
Report of childhood:
Emotional Abuse 10.6 percent
Physical Abuse 28.3 percent
Sexual Abuse 20.7 percent
Emotional Neglect 14.8 percent
Physical Neglect 9.9 percent
Total population percentage 68

69. Pediatric Approved Antipsychotics
Irritability due to autism Risperdal (risperidone) 5-17 Abilify (aripiprazole) 6-17 Schizophrenia Bipolar I Risperdal (risperidone) 13– Abilify (aripiprazole) Zyprexa (olanzapine) Seroquel (quetiapine) Invega (paliperidone)* Saphris (asenapine)* 10-17
*Newest antipsychotic medications approved for pediatric treatment. Fewer data in youth available.

70. Overview
Most pediatric treatment is for “off label” treatment of severe aggression and irritability
Safety monitoring: weight/height, fasting labs (glucose, cholesterol/lipids, liver function) at baseline and follow up; ECG for some medications
Risk of new onset diabetes
Non-adherence is common
Medication titration often necessary
Watch for early onset side effects: sedation, constipation, dry mouth, movement disorders
Medication trial usually 4–8 weeks to see greatest response

71. Stimulant Medications
Methylphenidate
Ritalin
Methylin
Ritalin LA
Ritalin SR
Metadate CD
Concerta
Focalin
Focalin XR
Daytrana Patch
Quillivant XR
Mixed amphetamine salts
Adderall
Adderall XR
Dextroamphetamine
Dexedrine
Dexedrine spansules
Vyvanse

72. Stimulant Medications
Used to target both hyperactivity and inattention
Benefit of a medication dose evident quickly: don’t need to wait weeks to see an effect
Medication can be held abruptly without physical withdrawal
Baseline: check weight, height, blood pressure
Monitor: sleep/appetite, tics, irritability, increased blood pressure/pulse
Refer to PCP: delays in growth, abnormal BP

73. Maryland Early Intervention Program
“A collaborative for the early identification and
treatment of mental illness with psychosis”

74. Centralized Contact For Services
Website:
Toll free numbers
Phone: 877–277–MEIP (6347)
Fax: 877–689–9185
Centralized
Staffed by a trained specialist
Master’s-level clinician.
9 a.m. to 5 p.m. Mondays through Fridays.
For emergency situations, please call 911 or go to your nearest emergency room before contacting the EIP.

75. Dr. Hewitt “Rusty” Clark
Presenter Contact Information
Dr. Hewitt “Rusty” Clark
Dr. Gloria Reeves

76. Contact DSG If you have questions or need additional information
about this Webinar,
contact Development Services Group, Inc.
Dr. Charles E. Lewis Jr.
Training Director
for the Minority Fellowship Program
Coordinating Center