Characteristics, Service Experiences, and Outcomes of Transition-Aged Youth in Systems of Care: Programmatic and Policy Implications

Clinical Update: Child and Adolescent Behavioral Health Care in Community Systems of Care

OBJECTIVE

The objective of this Clinical Update is to review the principles, structures, processes, and outcomes of community systems of care as they pertain to the delivery of behavioral health care to children and adolescents METHOD: A search of the literature on this topic from 2002 was initially conducted in 2016 and repeated in 2019 and 2021, yielding 1,604 English-language citations. These citations were supplemented by references suggested by topic experts and identified through Web searches, increasing the yield to 1,684 total citations, of which 1,184 were unduplicated. After sequential review by Update authors at title/abstract and then full-text levels, the citations were winnowed to 156 based on relevance to the topic.

RESULTS

The systems of care approach, arising in the 1980s, expanded child and adolescent behavioral health care from the core services of psychotherapy, medication management, inpatient psychiatric services, and residential treatment to include home- and community-based treatment and support services; promotion, prevention, and early intervention programs; and specialized services for very young children and youth and young adults of transition age. These services and supports are delivered by a large multidisciplinary workforce and are governed by key principles, including a biopsychosocial case conceptualization; family-driven, youth-guided, strengths-based, and trauma-informed care. Services in the least restrictive setting; continuity of care across transitions; a public health framework for service delivery; promotion of wellness and resilience; and elimination of health disparities. Challenges to systems of care implementation include funding availability, workforce shortages, deficiencies in cross-systems collaboration, and variability in insurance coverage. Although controlled studies have failed to provide convincing evidence of favorable outcomes from the whole systems of care approach, uncontrolled research has demonstrated increased access to care, positive clinical and functional outcomes, improved family functioning, and reductions in costs, particularly when research is focused on specific behavioral health problems, specific interventions such as Wraparound care, or highly specified groups of youth.

CONCLUSION

Health professionals who are educated in the systems of care approach can improve access to and quality of behavioral health care for children and adolescents with behavioral health needs.

Roles of peer specialists and use of mental health services among youth with serious mental illness

AIM

To examine whether roles of peer specialists affect service use among Black, Latinx and White youth ages 16-24 with serious mental illness (SMI) in Los Angeles and San Diego Counties.

METHODS

Administrative data from 2015 to 2018 was used to summarize service use among 6329 transition age youth age 16-24 with SMI who received services from 76 outpatient public mental health programs with peer specialists on staff. Roles of peer specialists were assessed via a program survey. Generalized linear models were used to assess the relationship between peer specialist characteristics and service use outcomes (ie, outpatient and inpatient).

RESULTS

Having a transition age youth peer specialist on staff (vs older peer specialists) and having peer specialists that provide four or more services (vs fewer services) was associated with an increase in annual outpatient visits in both counties (P = <.001 each). In Los Angeles County, having three or more peer specialist trainings (vs fewer trainings) was associated with lower use of inpatient services (P < .001). In San Diego County, having a transition age youth peer specialist and peer specialists that provide four or more services was associated with lower use of inpatient services (P < .001 each).

CONCLUSIONS

Types of peer support and number of types of peer services were associated with mental health service utilization. Detailed examination of the roles of peer specialists is merited to identify the specific pathways that improve outcomes.

Predicting Child-to-Adult Community Mental Health Service Continuation

Serious mental health conditions peak in prevalence and incidence during the transition to adulthood (approximately ages 16-25). Young adults are at high risk for discontinuation of care when no longer eligible for child mental health services. This study uses state administrative data to examine service continuation among those aging out of child system services in Texas (N = 3135). Most (63.5%) did not enroll in adult services following their 18th birthday. Binary logistic regression analyses found that significant predictors of child-to-adult service continuation included (1) a serious primary mental health diagnosis (i.e., schizophrenia, bipolar disorder, major depressive disorder), (2) risks to self and others, and (3) number of prior-year mental health services received. These findings suggest that historical mental health policies and practices may contribute to service disconnection at age 18 in Texas. Implications for mental health policy and system reform locally and nationally are discussed.

The Availability of Peer Support and Disparities in Outpatient Mental Health Service Use Among Minority Youth with Serious Mental Illness

We examine whether the availability of peer support reduces disparities in service use among minority youth ages 16-24 with serious mental illness in Los Angeles and San Diego Counties. Administrative data from 2015-2018 was used to summarize service use among 13,363 transition age youth age 16-24 with serious mental illness who received services from 183 outpatient public mental health programs; 17.2% were Black, 67.4% were Latinx, and 15.4% were non-Latinx white. The availability of peer support was assessed via a program survey. Generalized linear models were used to assess the relationship between availability of peer support, defined as having a peer specialist on staff, and the annual number of outpatient mental health visits. We also examined the relationship between racial/ethnic concordance of youth and peer specialists and use of outpatient services. Forty-six percent of youth received services from programs that employed peer specialists. Among youth in both counties, the availability of peer support was associated with an increase in annual outpatient visits (P ≤ .05 each). Peer support was associated with reductions in service use disparities among Black and Latinx youth in Los Angeles County (P < .001 each). Peer concordance was associated with an increase in outpatient service use among Latinx youth in both counties (P < .05 each). Peer support was associated with increases in use of outpatient mental health services. Detailed examination of the context for youth peer support implementation is merited to identify the specific pathways that improve outcomes.

Factors Associated with Perceived Continuity of Care Among Patients Suffering from Mental Disorders

This cross-sectional study identified variables associated with continuity of care among 327 patients with mental disorders receiving services from a variety of professionals in different Quebec settings. Based on the Andersen's Behavioral Model, a linear regression analysis was performed. Attention deficit and mood disorders were negatively associated with continuity of care, while substance use disorders and quality of life revealed positive associations. Consulting a psychologist was linked to weaker continuity of care whereas visiting a drug rehabilitation center, social support, and satisfaction with services were positively related. Fostering social support, comprehensive and integrated care, and facilitating access to psychologists could lead to improved continuity of care.

A randomized controlled trial of a six-session cognitive behavioral treatment of emotional disorders in adolescents 14-17 years old in child and adolescent mental health services (CAMHS)

Background

This study aims to investigate effectiveness of a 6-week, transdiagnostic cognitive behavioral therapy (CBT) for anxiety and depression in adolescents, the Structured Material for Therapy (SMART), in naturalistic settings of child and adolescent mental health outpatient services (CAMHS).

Methods

A randomized controlled trial with waiting list control (WLC) was performed at three community CAMHS in Norway. Referred adolescents (N = 163, age = 15.72, 90.3% girls) scoring 6 or more on the emotional disorders subscale of the Strengths and Difficulties Questionnaire (SDQ) were randomly assigned to SMART or to WLC.

Results

In the treatment group (CBT), 32.9% improved in the main outcome measure (SDQ), compared to 11.6% in the WLC. Clinically significant and reliable change was experienced by 17.7% in the CBT condition, compared to 5.8% in the WLC. No patients deteriorated. Statistically significant treatment effects were achieved for internalization symptoms, anxiety symptoms and general functioning.

Conclusions

These promising findings indicate that SMART may be considered as a first step in a stepped care model for anxiety and/or depression treatment in CAMHS. The recovery rates imply that further investigations into the effectiveness of brief treatments should be made. Furthermore, there is a need for more comprehensive second-stage treatments for some of these patients.

Trial registration

ClinicalTrials.gov Identifier: NCT02150265. First registered May 292,014.

An Evidence Map for Interventions Addressing Transition from Pediatric to Adult Care: A Systematic Review of Systematic Reviews

PROBLEM

Adolescents and young adults with chronic illnesses continue to face barriers as they transition from pediatric to adult care. An evidence map can help to identify gaps in the transition literature to determine targets for future research.

ELIGIBILITY CRITERIA

We searched PubMed, CINAHL, PsycInfo, and Cochrane for systematic reviews published through February 2018. Eligible reviews included at least one comparative study testing a youth-focused intervention for improving transition with at least one quantitative health-related outcome reported.

SAMPLE

We identified 431 unique reviews in our search, and 37 reviews (containing 71 eligible primary studies) met inclusion criteria.

RESULTS

Most reviews (20 of 37) summarized some aspect of transition across diagnoses. Type 1 diabetes was the most common diagnosis studied (7 of 37 reviews and 24 of 71 primary studies). Only 14 of 71 primary studies focused on care after transfer to adult care.

CONCLUSIONS

The literature on interventions to improve transition to adult care has focused on a limited number of diagnoses, most commonly Type 1 diabetes. Common pediatric conditions, such as asthma, have not been studied with regard to transition. Efforts have been mainly targeted on transition preparation, with less focus on transition needs after transfer to adult care.

IMPLICATIONS

There is a need for transition research focused on common pediatric conditions and transition needs after transfer to adult care.

Measuring Functional Impairment in Children and Adolescents: Psychometric Properties of the Columbia Impairment Scale (CIS)

The role of measuring functional impairment holds an important place in research, clinical practice, and service provision for children and adolescents. Responding to the growing need to measure serious emotional disturbances at the local, state, and national level, the Columbia Impairment Scale (CIS) was developed in the early 1990s and has remained one of the several popular scales for assessing functional impairment. However, despite the growing popularity of the instrument in research and practice, only a few studies to date have specifically examined the psychometric properties of the CIS. In this article, we describe the results of the first item response theory analysis of the CIS utilizing nationally representative data from the Medical Expenditure Panel Survey (N = 69,966). The results of our analysis lend support to the essential unidimensionality of the CIS and demonstrate that the scale is most reliable for those who exhibit high levels of functional impairment. Given the psychometric properties of the scale identified by our analysis, we contend that the CIS is a viable measure in the ongoing efforts to establish a national epidemiologic surveillance system to track the prevalence and impact of serious emotional disturbances in children and adolescents.

Transition to Adult Mental Health Services for Young People With ADHD

OBJECTIVE

To investigate the care management and continuity from child to adult mental health service for young adults with ADHD.

METHOD

A questionnaire survey from 18 Regional ADHD Pediatric Centers (RAPC) in Lombardy, Italy, was used to collect data on transition protocols and population served, and to track the pathway of care of ADHD patients once they reached adulthood.

RESULTS

Twenty-eight percent of RAPC had transition protocols and 3% of the population annually served were potential referrals to adult service. Of 52 patients who turned 18 years, just over 70% were monitored by the general practitioner, of those 5 with RAPC support. One fifth of patients continued to use mental health services, the majority was still monitored by the RAPC, and only three by services for adult.

CONCLUSION

Managing the process of transition to adult services in mental health care remains a need to be prioritized and better defined for ADHD patients.

Psychotropic medications for highly vulnerable children

INTRODUCTION

At least 20% of children in the U.S. are highly vulnerable because they lack healthcare and protection. Several factors produce vulnerability: trauma, disruptions of parenting, poverty, involvement in the juvenile justice and/or child welfare systems, residence in restrictive settings, and problems related to developmental disabilities. These children receive psychotropic medications at high rates, raising numerous concerns.

AREAS COVERED

The authors begin this review with a description of the population of highly vulnerable children. They then follow this with a review of the effectiveness and side effects of psychotropic medications for their most common diagnoses, using the highest-quality systematic reviews identified by multiple database searches.

EXPERT OPINION

Highly vulnerable children receive numerous psychotropic medications with high rates of polypharmacy, off-label use, and long-term use, typically in the absence of adjunctive psychosocial interventions. The current evidence contravenes these trends. Future studies of psychotropic medications in vulnerable children should include long-term effectiveness trials and polypharmacy in conjunction with evidence-based, family-centered, psychosocial treatments.

Therapist- and Client-Level Predictors of Use of Therapy Techniques During Implementation in a Large Public Mental Health System

OBJECTIVE

Many youths receiving community mental health treatment do not receive evidence-based interventions. Research suggests that community mental health therapists use a broad range of therapeutic techniques at low intensities. This study examined the relationship between therapist- and client-level predictors of community-based therapists' report of cognitive, behavioral, psychodynamic, and family techniques within the context of implementation efforts.

METHODS

A total of 130 therapists participated from 23 organizations in an urban, publicly funded behavioral health system implementing evidence-based practices. Therapist-level predictors included age, gender, clinical experience, licensure status, and participation in evidence-based practice initiatives. Child-level predictors included therapist-reported child primary disorder (externalizing, internalizing, or other) and child age. Therapists completed the Therapist Procedures Checklist-Family Revised, a self-report measure of therapeutic techniques used.

RESULTS

Unlicensed therapists were more likely than licensed therapists to report using psychodynamic and behavioral techniques. Therapists who did not participate in an evidence-based practice initiative were less likely to report use of cognitive techniques. Those with clients with externalizing disorders were more likely to report use of behavioral and family techniques. Therapists with the youngest clients (ages three to seven years) were most likely to report use of behavioral techniques and less likely to report use of cognitive and psychodynamic techniques.

CONCLUSIONS

Results suggest that both therapist and client factors predict self-reported use of therapy techniques. Participating in an evidence-based practice initiative was associated with increased reports of using cognitive techniques. Therapists reported using behavioral and family techniques more than other techniques when working with youths with externalizing disorders and using fewer cognitive and psychodynamic techniques with young clients.

Assessing and changing organizational social contexts for effective mental health services

Culture and climate are critical dimensions of a mental health service organization's social context that affect the quality and outcomes of the services it provides and the implementation of innovations such as evidence-based treatments (EBTs). We describe a measure of culture and climate labeled Organizational Social Context (OSC), which has been associated with innovation, service quality, and outcomes in national samples and randomized controlled trials (RCTs) of mental health and social service organizations. The article also describes an empirically supported organizational intervention model labeled Availability, Responsiveness, and Continuity (ARC), which has improved organizational social context, innovation, and effectiveness in five RCTs. Finally, the article outlines a research agenda for developing more efficient and scalable organizational strategies to improve mental health services by identifying the mechanisms that link organizational interventions and social context to individual-level service provider intentions and behaviors associated with innovation and effectiveness.

Mental disorders and transition to adult mental health services: A scoping review

Background

Data are progressively accumulating regarding the transition to adult services.

Methods

A comprehensive search using the MEDLINE, Embase, PsycINFO, and Cochrane databases up until 16 March 2015 was conducted in order to summarize recent evidence on the transition from child to adult mental health services for patients with mental disorders. Authors extracted data and assessed study quality independently.

Results

The main findings of the 33 included studies were discussed taking into consideration four aspects: experiences of patients, carers, and clinicians, accounts of transition, current services models and protocols, and outcomes of transition. Of the 33 studies, 17 focused on a specific mental disorder: seven on attention deficit hyperactivity disorder, four on intellectual disability, three on eating disorders, two on serious emotional disorders and one on autism spectrum disorder. An attempt was also made to integrate the studies’ conclusions in order to improve transitional care.

Conclusions

The review reveals an evident need for longitudinal, controlled, health services research to identify and evaluate optimal service models with systematic and seamless transition protocols for patients with mental disorders requiring continuity of care into adult mental services.

Update on the Improving Access to Psychological Therapies programme in England: Commentary on … Children and Young People's Improving Access to Psychological Therapies

Professor Sami Timimi recently expressed concerns about the Improving Access to Psychological Therapies (IAPT) programme. We argue that the concerns are largely unfounded and provide readers with an update on the programme.

Evaluating change in symptomatic and functional level of children and youth with emotional disorders: a naturalistic observation study

The objective of the study is to describe the changes in symptomatic and functional impairment for children and youth with emotional disorders treated at child and adolescent mental health outpatient services (CAMHS) in Norway. The study was of naturalistic observational type in which the treatment can be classified as "treatment as usual" (TAU). The Strengths and Difficulties Questionnaire (SDQ), the Health of the Nation Outcome Scale (HONOSCA) and the Children's Global Assessment Scale (CGAS) were used as measures of change. The information from multiple informants allowed the evaluation of change from different perspectives. The sample consisted of 84 children and youth with emotional disorders treated at two CAMHS in the North of Norway. The SDQ, the HONOSCA and the CGAS were administered at intake (T0), during assessment (T1) and approximately, 6 months after T1 (T2). Change was analysed by means of the Linear Mixed Models procedure. The results show that children and youth with emotional disorders experience a statistically significant improvement per month during outpatient treatment according to nearly all the measures of change. For the clinician rated scores, change rates during active assessment/treatment were larger than during the waitlist period. Evaluating change from the perspective of clinical significance showed that only a small proportion of the subjects had change scores that were statistically reliable and clinically significant. Whether an actual change has occurred is uncertain for the majority of patients.

Components of a TIP Model Program

Transition-aged youth in need of services and supports find themselves in a quandary; in certain instances, they are considered children, whereas in other circumstances, they qualify as adults. Transition to Independence Process (TIP) provides a promising model for transition-aged youth programs. It is distinguished by an emphasis upon client-driven goals, as opposed to agency-defined goals. Another key feature is reliance upon collaboration among service providers in order to address the myriad of needs of young adults. From the perspective of transition-aged clients, an efficacious TIP program must offer support services, including mental health care. It must encourage natural supports, including family. All of the facets of a TIP model program should have as their ultimate focus the education and employment of transition-aged youth. Together, these contribute to the best possible outcomes for transition-aged youth.

Transition to adult services for young people with mental health needs: A systematic review

BACKGROUND

Young people's transition from child and adolescent (CAMHS) to adult mental health services (AMHS).

OBJECTIVES

To systematically review evidence on the effectiveness of different models of CAMHS-AMHS transitional care, service user and staff perspectives, and facilitators of/barriers to effective CAMHS-AMHS transition.

DATA SOURCES

A systematic search in May 2012 of Medline, PsycINFO, CINAHL, EMBASE, AMED, Health Business Elite, HMIC, Cochrane Database, Web of Science and ASSIA; ancestral searches; and consultation with experts in the field.

STUDY SELECTION

Qualitative, quantitative and mixed-methods primary research on the CAMHS-AMHS health-care transition of young people (aged 16-21 years) with mental health problems.

DATA EXTRACTION

Two reviewers independently completed a standardised data extraction form and critically evaluated identified documents using a validated appraisal tool for empirical studies with varied methodologies.

RESULTS

A total of 19 studies of variable quality were identified. None were randomised or case-controlled trials. Studies incorporating service user/carer perspectives highlighted the need to tackle stigma and provide accessible, age-appropriate services. Parents/carers wanted more involvement with AMHS. Transitional care provision was considered patchy and often not prioritised within mental health services. There was no clear evidence of superior effectiveness of any particular model.

CONCLUSIONS

High-quality evidence of transitional care models is lacking. Data broadly support the development of programmes that address the broader transitional care needs of 'emerging adults' and their mental health needs but further evaluation is necessary. Developing robust transitional mental health care will require the policy-practice gap to be addressed and development of accessible, acceptable, responsive, age-appropriate provision.

Predicting Positive Education Outcomes for Emerging Adults in Mental Health Systems of Care

Emerging adults who receive services based on positive youth development models have shown an ability to shape their own life course to achieve positive goals. This paper reports secondary data analysis from the Longitudinal Child and Family Outcome Study including 248 culturally diverse youth ages 17 through 22 receiving mental health services in systems of care. After 12 months of services, school performance was positively related to youth ratings of school functioning and service participation and satisfaction. Regression analysis revealed ratings of young peoples' perceptions of school functioning, and their experience in services added to the significant prediction of satisfactory school performance, even controlling for sex and attendance. Finally, in addition to expected predictors, participation in planning their own services significantly predicted enrollment in higher education for those who finished high school. Findings suggest that programs and practices based on positive youth development approaches can improve educational outcomes for emerging adults.

Pre-Practicum Training in Professional Psychology to Close the Research-Practice Gap: Changing Attitudes Towards Evidence-Based Practice

Despite the rapid proliferation of mental health interventions with proven benefit for youth, empirically supported interventions (ESIs) are underutilized in most service settings. Treatment outcome studies in these community-based settings suggest that the majority of youth do not show improvement, underscoring the importance of addressing the gap between research and practice. Clinician attitudes toward evidence-based practice (EBP) may limit the use of ESIs, and efforts to address these attitudes with post-graduate training pose significant challenges. Pre-practicum training in EBP may address these challenges by familiarizing students with the framework of EBP as well as with the current youth treatment evidence base and the theories and strategies of well-supported interventions. We describe a required EBP course within a professional psychology doctoral program. Forty-two students in two class cohorts completed a measure of attitudes toward EBP prior to the first class and after the final class lecture. Students were predominantly Caucasian women with bachelor's degrees. As expected, over the course of the class, student attitudes became significantly more favorable toward EBP. Students who had previously received a master's degree had more favorable attitudes prior to the class, and students with a prior bachelor's degree showed the greatest change in attitude. The results support the use of pre-practicum training in EBP to improve attitudes toward EBP, which may lead to use of effective practices with clients following training.

Developing a community-based participatory research model to engage transition age youth using mental health service in research

We present a model for the development and conduct of a community-based participatory research project with transition age youth (TAY) mental health service users. Community-based participatory research frameworks can facilitate equitable partnerships and meaningful inclusion but have not been fully drawn upon in mental health research. The model included TAY as trained research associates involved in every aspect of the research process. We describe the development of the project, creation of the research team, training, the design and conduct of the study, and challenges faced. The methods developed successfully provided support for the meaningful participation of TAY in the project.

Consultants' perceptions of school counselors' ability to implement an empirically-based intervention for adolescent social anxiety disorder

Social anxiety is highly prevalent but goes untreated. Although school-based CBT programs are efficacious when delivered by specialized psychologists, it is unclear whether school counselors can implement these interventions effectively, which is essential to promote sustainable school programs. We present an initial consultation strategy to support school counselor implementation of group CBT for social anxiety and an evaluation of counselors' treatment fidelity. Counselors were highly adherent to the treatment, but competence varied based on measurement. Counselors and consultants demonstrated good agreement for adherence, but relatively modest correspondence in competence ratings. We discuss future directions for school-based implementation efforts informed by these initial findings.

How Community Organizations Promote Continuity of Care for Young People with Mental Health Problems

Young people between the ages of 16 and 25 who experience mental health problems experience transitions and need help from a variety of organizations. Organizations promote continuity of care by assisting young adults with developmental, service, and systemic transitions. Providers offer specific services to help transitions and also form cooperative relationships with other community organizations. Results from a survey of 100 service providers in one community describe organizational attributes and practices which are associated with continuity of care in a regional system for young adults. Data analyses show that full-service organizations which practice cultural competence offer more specific services that foster continuity of care. Larger, full-service organizations are also more likely to have more extensive and collaborative inter-organizational networks that help young adults continue care over time within the regional system of care.

Use of mental health services in transition age youth with bipolar disorder

OBJECTIVES

There is concern that treatment of serious mental illness in the United States declines precipitously following legal emancipation at age 18 years and transition from specialty youth clinical settings. We examined age transition effects on treatment utilization in a sample of youth with bipolar disorder.

METHODS

Youth with bipolar disorder (N=413) 7-18 years of age were assessed approximately twice per year (mean interval 8.2 months) for at least 4 years. Annual use of any individual, group, and family therapy, psychopharmacology visits, and hospitalization at each year of age, and monthly use from ages 17 through 19 years, were examined. The effect of age transition to 18 years on monthly visit probability was tested in the subsample with observed transitions (n=204). Putative sociodemographic moderators and the influence of clinical course were assessed.

RESULTS

Visit probabilities for the most common modalities-psychopharmacology, individual psychotherapy, and home-based care- generally fell from childhood to young adulthood. For example, the annual probability of at least one psychopharmacology visit was 97% at age 8, 75% at age 17, 60% at age 19, and 46% by age 22. Treatment probabilities fell in transitionage youth from age 17 through 19, but a specific transition effect at age 18 was not found. Declines did not vary based on sociodemographic characteristics and were not explained by changing severity of the bipolar illness or functioning.

CONCLUSIONS

Mental health treatment declined with age in this sample of youth with bipolar disorder, but reductions were not concentrated during or after the transition to age 18 years. Declines were unrelated to symptom severity or impairment.

Children First

Although the importance of healthy mental development in children and youth is not disputed, the mental health needs of far too many Canadian children are being ignored. Within the context of recent federal and provincial calls for systemic reform of the mental health care systems for children and youth, we underscore the necessity for ongoing innovation, development, education, and evaluation. This article describes our aims to establish demonstration and research sites focused on promising frameworks that draw from systems of care, public health, and resiliency approaches.

Mental Health and Substance Use Disorders among Foster Youth Transitioning to Adulthood: Past Research and Future Directions

At a time when there is increasing attention being given to systematically integrating the well-being of children with the goals of safety and permanence in child welfare, little is known about the psychosocial functioning of foster youth transitioning to adulthood from substitute care. This article systematically reviews 17 peer-reviewed articles and/or research reports to identify lifetime and past year prevalence rates of mental health disorders and service utilization. At ages 17 or 18, foster youth are 2 to 4 times more likely to suffer from lifetime and/or past year mental health disorders compared to transition aged youth in the general population. Findings show that mental health service use declines at ages when the prevalence rate of mental health disorders is peaking. The findings of this review suggest the need to focus future efforts in three main areas: 1) Setting a common research agenda for the study of mental health and service use; 2) Routine screening and empirically supported treatments; and 3) Integration and planning between child and adult mental health service systems.

Improving community-based mental health care for children: translating knowledge into action

There is urgent need for improvement in community-based mental health care for children and families. Multiple studies have documented serious limitations in the effectiveness of "usual care." Fortunately, many empirically-supported strategies to improve care have been developed, and thus there is now a great deal of knowledge available to address this significant public health problem. The goal of this selective review is to highlight and synthesize that empirically-supported knowledge to stimulate and facilitate the needed translation of knowledge into action. The review provides a sound foundation for constructing improved services by consolidating descriptive data on the status quo in children's mental health care, as well as evidence for an array of promising strategies to improve (a) Service access and engagement; (b) Delivery of evidence-based practices; and (c) Outcome accountability. A multi-level framework is used to highlight recommended care improvement targets.

Are children improving? Results from outcome measurement in a large mental health system

Standardized outcome assessment was implemented in a large county mental health system. This study examines changes in children's emotional and behavioral problems after 6 months of treatment and identifies factors associated with treatment improvement. Results from 3,215 youth indicated that externalizing and internalizing problems significantly decreased from intake to 6 months and that ethnicity, gender, and age were associated with caregiver-reported changes in symptomatology. While there was improvement associated with entry into treatment, the magnitude of symptom reduction was small to medium and not associated with amount of care, providing only limited support for the impact of routine out-patient care.

Perceptions of family environment and wraparound processes: associations with age and implications for serving transitioning youth in systems of care

Addressing the unique needs of youth transitioning to adulthood has long been viewed as a priority in implementation of systems of care (SOCs) and wraparound. Developmental research and "practice-based evidence" suggest that there are differences between transitioning youth and their younger peers in family environment and wraparound team processes. Although these differences are thought to have significant implications for wraparound practice, few studies have examined them empirically. The present research involves two studies examining differences across several age cohorts (i.e., 10–12, 13, 14, 15, 16–17 year-olds) ranging from early adolescent to transitioning youth in: (1) caregiver perceptions of role-related strain and family environment quality, and (2) facilitator, caregiver, and youth perceptions of wraparound processes. In Study #1, older age was associated with higher levels of caregiver strain. In Study #2, age was associated with differences between youth and other team members' perceptions of wraparound processes, such that older youth perceived teams as less cohesive than others on their teams. These findings suggest that transitioning youth and their families merit special consideration in wraparound implementation and underscore the importance of considering the perceptions of transitioning youth in system change and practice improvement efforts (192 words).

Transition experiences of mental health service users, parents, and professionals in the United Kingdom: a qualitative study

OBJECTIVE

The aim of this study was to describe the experiences of child and adolescent mental health service (CAMHS) users, parents and professionals in relation to transition between CAMHS and adult mental health services (AMHS) in the United Kingdom.

METHODS

Young people were sampled from an observational study population of people reaching the transition boundary between CAMHS and AMHS. We thematically analyzed qualitative interviews with service users, parents and clinicians.

RESULTS

Eleven service users were interviewed and linked interviews were completed with parents (n=6), and responsible clinicians in CAMHS (n=3) and AMHS (n=6). Informal and gradual preparation, transfer planning meetings, periods of parallel care, and consistency in key-workers promoted positive experiences of transition. Transfers between AMHS, changes of key-worker and waiting lists were viewed negatively. Other life transitions, including changes in housing, pregnancy, physical illness, and the involvement of parents or other services were sometimes powerful extraneous influences on transition experiences.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

The cumulative effect of multiple transitions is a complex and unsettling experience for many service users. Service user experiences are more likely to be positive if healthcare transition is a gradual process, tailored to the young person's needs and managed in the context of the other simultaneous practical, developmental and psychosocial transitions. Transfer planning meetings and parallel care were valued by all parties and should be standard practice at transition. CAMHS and AMHS need to work jointly to improve the transition process in these ways in order to enhance the outcomes for young people.

Adapting services to engage young adults in ICCD clubhouses

TOPIC

This article describes efforts to develop and offer supports for young adults within two clubhouse programs affiliated with the International Center for Clubhouse Development (ICCD).

PURPOSE

In response to a need to address service gaps and create supports to engage young adults transitioning to the adult mental health system, the authors describe the background, development, and adaptations of services and supports for young adults within their respective clubhouse programs. The authors highlight details and challenges associated with program adaptation and success stories of transition aged youth actively engaged in their clubhouses.

SOURCES USED

Published literature, personal observation, and member feedback.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

These clubhouse programs share successful strategies used to engage young adults including outreach efforts led by young adults, developing supports and linkages with local educational institutions, addressing housing issues specific to young adults, and using current technologies that young adults find appealing. These strategies may prove useful to other service models that serve this population. Clubhouses affiliated with the ICCD show promise in expanding their approach and services to engage and support young adults.

Ambulante und teilstationäre Jugendhilfe-Maßnahmen

Fragestellung: In der vorliegenden Studie wird die langfristige Wirksamkeit ambulanter und teilstationärer Jugendhilfe-Maßnahmen untersucht. Dazu werden die Entwicklungen im Bereich des allgemeinen Belastungsausmaßes, expansiver Verhaltensprobleme, emotionaler Probleme sowie der Ressourcenaktivierung ausgewertet. Zudem gehen Fragen zur Ausbildungssituation, Legalbewährung und zum Substanzmissbrauch der Jugendlichen in die Analysen ein. Methodik: Anhand quantitativer Daten aus drei Erhebungszeitpunkten werden die Entwicklungsverläufe ehemals durch die Jugendhilfe betreuter Kinder, Jugendliche und ihrer Familien (N = 59) betrachtet. Ergebnisse: Zunächst ließen sich am Hilfebeginn drei Gruppen mit signifikant unterschiedlichen Belastungsausmaßen (niedrig-, mittel- und hochbelastet) bestimmen. Dabei wurde angenommen, dass die Hilfen in stärkerem Maße niedriger belastete Kinder und Jugendliche erreichen. Es konnte aufgezeigt werden, dass am Hilfebeginn stärker belastete Kinder und Jugendliche auch drei Jahre nach dem Hilfeende signifikant höhere Problembelastungen sowie familiäre Belastungen aufweisen; für Verhaltensprobleme liegen zwischen den Gruppen jedoch keine signifikanten Unterschiede vor. Schlussfolgerungen: Dies verweist auf eine unabhängig vom Belastungsausmaß langfristige Wirksamkeit von Jugendhilfe-Maßnahmen.

Research on transition to adulthood: building the evidence base to inform services and supports for youth and young adults with serious mental health disorders

Since the mid-1990s, research has established a clear picture of the poor real-life outcomes achieved by transition-age youth and young adults who have been diagnosed with a serious mental health disorder. The purpose of this article is to: (1) introduce the reader to the other eight articles in this special issue on Transition to Adulthood Research; (2) illustrate how each is contributing to the research base available to more fully understand these challenges as well as guide the creation of developmentally appropriate and effective services and supports for youth and young adults and their families; and (3) suggest future directions for continuing to advance this field of research and program implementation to improve outcomes though practice and policy improvements.