Maryann Davis, Ph.D. Research Associate Professor

1. Evidence-Based Treatments and Mental Health Issues for Young Adults:What They Need and What We Need to Do Maryann Davis, Ph.D. Research Associate Professor Director: Transitions Research & Training Center Center for Mental Health Services Research Department of Psychiatry University of Massachusetts Medical School

2. Acknowledgements • Major Collaborators: • Charles Lidz, Ph.D., William Fisher, Ph.D., Lisa Mistler, MD., • UMass Medical School, Center for Mental Health Services Research, Dept. of Psychiatry • Ashli J. Sheidow , Ph.D., Michael McCart, Ph.D., Scott Henggeler, Ph.D. Medical University of SC, Family Services Research Center, Dept of Psychiatry and Behavioral Sciences Edward Mulvey, Ph.D., Univ. of Pittsburgh Medical School, Dept of Psychiatry, Mary Evans, Ph.D., University of South Florida, Dept of Nursing and Public Health • Funding from NIMH (R01 MH067862-01A1, R34-MH081303-01, R34 MH081374-01, RC1MH088542-02), and NIDRR & SAMHSA (H133B090018), UMass Medical School’s Commonwealth Medicine • Visit us at: http://labs.umassmed.edu/TransitionsRTC • The content of this presentation does not necessarily reflect the views of the funding agencies, nor their endorsement

3. Overview • Why this age group needs specific Evidence Based Treatments/Practices (EBT/P’s) • EBT/P’s in development • Shared features of EBT/P’s

4. Serious Mental Health Conditions (SMHC) • Serious Emotional Disturbance OR Serious Mental Illness OR Psychiatric Disability • MH diagnosis causes substantial functional impairment in family, social, peer, school, work, community functioning, or ADLs • Not pervasive developmental disorders, substance use, LD, ID (these can co-occur) Transitions RRTC

5. Major causes of disease burden in Disability Adjusted Life Years IN THE WORLD Males Females Males Females Leading Neuropsychiatric Disorders causing DALYs: Unipolar Depression* (7.9-9.9%) Schizophrenia (4.2-5.3%) Bipolar Disorder (4/1-5.1%) Within top 6 causes of DALYs in 15-24 yr olds in the world World High Income Europe Americas 15-19 Year olds 20-24 Year olds • HIV, TB, malaria Maternal conditions • Other communicable diseases Other non-communicable diseases • Neuropsychiatric disorders Injuries Gore, FM., Bloem, PJN, Patton, GC, Ferguson, J, Joseph, V, Coffey, C, Sawyer, SM, & Mathers, CD (2011). Global burden of disease in young people aged 10–24 years: a systematic analysis. Lancet, DOI:10.1016/S0140-6736(11)60512-6

6. Complete schooling & training Be a good citizen Developmental Changes Underlie Abilities to Function More Maturely Contribute to/head household Obtain/maintain rewarding work Develop a social network Become financially self-supporting

7. Critical Window of Development • 6 Paths to Adulthood (marriage, parenting, education, residence, employment at age 24) • Fast starters (12%); high rates of marriage, parenting, school completion, home-ownership, employment for the future • Parents without Careers (10%); living with spouse/partner, not working/poor jobs (71%♀) • Educated Partners (19%); living w spouse/partner, no kids, higher education, career-step jobs Osgood, E.W., Ruth, G., Eccles, J.S., Jacobs, J.E., & Barber,, B.L (2005). Six paths to adulthood. In R.A. Settersten, F.F. Furstenberg, & R.G. Rumbaut (Eds.). On the Fontier of Adulthood: Theory, Research, and Public Policy. Univ. Chicago Press. Pp320-355.

8. Critical Window of Development • 6 Paths to Adulthood cont’d(marriage, parenting, education, residence, employment) • Educated Singles (37%); most college completion, living w parents, career-step jobs, no partner/kids • Working Singles (7%); some college, living with parents (some own home), in job for future, no partner/kids • Slow Starters (14%); not well established in relationship, residence, employment or education, 25% w kids. Osgood, E.W., Ruth, G., Eccles, J.S., Jacobs, J.E., & Barber,, B.L (2005). Six paths to adulthood. In R.A. Settersten, F.F. Furstenberg, & R.G. Rumbaut (Eds.). On the Fontier of Adulthood: Theory, Research, and Public Policy. Univ. Chicago Press. Pp320-355.

9. Youth with SMHC Struggle as Young Adults Valdes et al., 1990; Wagner et al., 1991; Wagner et al., 1992; Wagner et al., 1993; Kutash et al., 1995; Silver et al., 1992; Embry et al., 2000; Vander Stoep, 1992; Vander Stoep and Taub, 1994; Vander Stoep et al., 1994; Vander Stoep et al., 2000; Davis & Vander Stoep, 1997; Newman et al., 2009

10. Functioning in Adults with Psychiatric Disorders; Young Adults Different from Mature Adults *2 (df=1)=31.4-105.4, p<.001 ** 2 (df=1)=5.5, p<.02

11. Young adults ages 18-25 with a serious mental illness • 48% report past-year illicit substance use • 36% meet criteria for a Substance Use Disorder (SAMHSA, 2003) Swendsen, J., Anthony, J.C., Conway, K.P., Degenhardt, L., Dierker, L., Glantz, M., He, J., Kalaydjian, A., Kessler, R.C., Sampson, N., & Merikangas, K.R. (2008). Improving targets for the prevention of drug use disorders: Sociodemographic predictors of transitions across drug use stages in the national comorbidity survey replication. Preventive Medicine: An International Journal Devoted to Practice and Theory. 47(6), 629-634.

12. Typical Cognitive Development INCREASING ABILITY TO THINK ABSTRACTLY Thinking hypothetically; "If I become pregnant I probably won't finish high school, but my boyfriend might marry me, but if he doesn't......." Planning;"Before I get an apartment I need to get a job, save money, and work on a budget." Insight; "Every time an older man questions what I do I get terribly angry - he reminds me of my father." These changes allow them to examine their choice process, and have a better understanding of themselves and others.

13. Cognitive Abilities Change Even to Age 30 • Anticipation of Consequences (Steinberg,et al., 2009) • Complex strategic planning (Albert & Steinberg, 2011) • Behavior control towards emotional stimuli (Hare et al., 2009, Liston et al., 2006) • Cognitive control over distracting stimuli (Christakou et al., 2009)

14. Typical Social Development • Friendships become more complex, involving mutuality, intimacy, and loyalty. • Peer relationships are of PARAMOUNTimportance. • Peer context changes; school to work transition

15. Typical Moral Development Externally reinforced rights and wrongs Rigid interpretation (applies to everyone in all situations) Empathic responses & Golden Rule Sacrifice for the greater good

16. Typical Identity Formation Answering the question; Who am I? Who am I that I am not my Parents? Who am I as a student, worker, romantic partner, parent, friend? Who am I in the World? What do I like to do and who do I want with me?

17. Typical Sexual Development Life-impacting and safety issues Address sexual orientation New types of intimacy Different roles in peer group

18. Psychosocial Development in Those with Serious Mental Health Conditions • Research limited to adolescence – but implications hold for emerging adults with histories of SMHC Psychosocial Delay on Every Front • Individuals will vary in their level of development • Individuals may be more mature in one area than another

19. Typical Changes in Family Relations Young people and parents must adjust to the growing need for independence while remaining emotionally related.

20. Family Characteristics of Youth with SMHC • History of separation from family • Single-parent & poverty (Wagner et al., 2006) • Youth and parents rate their families as more chaotic and lower in emotional bonding (Prange et al., 1992) • Parental mental health, incarceration, substance use

21. Developmental Implications Supports need to be developmentally appropriate

22. Developmental Implications Support Increased Self Determination Financially self-supporting and responsible Make Decisions Head a household

23. Making Services Appropriate for Developmental Stage • Examples: • If “executive functioning” less mature – make plans together for how to overcome distractions • Peer context important – group treatment settings that include much older or younger individuals may not appeal • Sexuality is important- build pregnancy and parenting plans (even if it is NOT in plan) into planning • Romantic relationships – social support may come from partner/spouse/boy or girl friend • Immature Identity Formation – resist urge to parent or be authority, allow for experimentation • Identity Formation Process – incorporate youth voice/ownership

24. Developmental Implications Need supports to launch adulthood • Families continue to be an important resource to their emerging adult child • Many families in the public sector struggle with poverty, single parenting, mental health, substance use, incarceration • Delicate dance of maximizing family as resources while supporting self-determination skills • Inclusion of other social network members, but less stability Settersten, Jr, R.A., Furstenberg, F.F., & Rumbaug, R.G. (2005). On the Frontier of Adulthood: Theory, Research, and Public Policy. Chicago, The University of Chicago Press.

25. Each Generation has its Youth Culture "In America, a flapper has always been a giddy, attractive and slightly unconventional young thing who, in [H. L.] Mencken's words, 'was a somewhat foolish girl, full of wild surmises and inclined to revolt against the precepts and admonitions of her elders.'"6 Transitions RTC

26. Transitions RTC

27. System considerations • Youngest adults still involved with child system • Adult services often not developmentally tailored • Funding of treatment/services have age barriers Prevalence of disrupted, complex, developmentally inappropriate treatment or services

28. Medicaid Disenrollment Rates within 365 Days in Young Adults Discharged from Inpatient Mental Health Treatment (n=1,176) Young Adults Discharged from Inpatient Psychiatric Treatment (n=1176) 32.2% Disenrolled Medicaid Enrollment Category Primary Care No Primary Care (n=168) 44.6% No Recent Disenrollment Recent Disenrollment F&C/CHIP (n=382) Disabled/Foster Care/Limited Coverage (n=794) (n=567)12.5% (n=227) 40.1% Age <22.6 Age >22.6 (n=53) 50.9% Age <20.1 Age >20.1 (n=85) 61.2% (n=76) 82.9%

29. What constitutes evidence? • Clinical Trials • Detailed description (manual) • Reliable method to confirm practice (fidelity) • Comparison groups (with and without practice) • Randomization to groups - RCT • Meta analyses – analyze multiple RCTs

30. What constitutes evidence? • When clinical trials are conducted within the age group (e.g. study of college intervention) • When clinical trials are conducted across a variety of ages • Have enough individuals in the transition age group • Conduct analyses to detect age differences

31. The current evidence base

32. Reported Age Differences • Different alcohol treatment approaches more effective in younger than older adults (Rice et al., 1993) • Effective recidivism reduction approach not effective in those under age 27 (Uggen, 2000) • Treatment of 1st episode psychosis, younger adults benefitted most from supportive counseling, older adults benefitted most from CBT (Haddock et al., 2006)

33. Employment Intervention Demonstration Program Supported Employment Randomized Trial 1.00 – .90 – .80 – .70 – .60 – .50 – .40 – .30 – Control SE Any Competitive Employment Burke-Miller, J., Razzano, L., Grey, D., Blyler, C., & Cook, J.(2012). Supported employment outcomes for transition age youth and young adults. Psychiatric Rehabilitation Journal, 35, 171-179. Ages 18-24 Ages 25-30 Ages 31+

34. Most in feasibility research stage Evidence Based Treatments in Development

35. Motivational Interviewing (MI) • Interpersonal style of therapy characterized by: • Affirming client choice and self-direction • Using directive and client-centered components • Context of a strong working alliance • To resolve client’s ambivalence about target problem, and increase perceived self-efficacy to address the problem Miller & Rose, 2009

36. MI cont’d • Efficacy in addictions in adolescents and adults (see Lundahl et al., 2010) • In college student (e.g. Baer et al., 2001) • “Preliminary research supports adding MI to existing treatments for most major mental health problems” (Westra, Aviram, & Doel, 2011) • Specific support for age group from 2 small trials; perinatal depression (Grote et al., 2009) and social anxiety disorder (Buckner & Schmidt, 2009)

37. Motivational Enhancement Therapy for Treatment Attrition • METs are structured Motivational Interviewing protocols, usually 1-4 sessions • MET/MI strong evidence of treatment attrition efficacy • Evidence in the small studies of young adults • BUT Diagnostic Specific

38. Transition Age Youth Quickly Lost from Treatment

39. MET-Treatment Attrition; Target Problem: Treatment Attrition For use with any psychotherapeutic approach with 18-25 year olds with any mental health condition Davis, Sheidow & Mistler

40. Cognitive Behavioral Therapy/Motivational Interviewing for High Risk Behavior (Henin, 2011) • 14 sessions of individual CBT • 2 additional booster sessions as needed • Sessions are flexible and adapted to the needs of each individual • Integrates both CBT and motivational interviewing techniques • Patient identifies a high-risk behavior and area of functioning that they want to work on

41. Developmental Adaptations • Issues of autonomy and self-concept • Acceptance of BPD diagnosis • Acceptance (or not) of medication • Peer-related issues • Therapist avoids parental role or position of absolute expert • Thinking of this age-range as a continuation of adolescence • Use of technology (e.g., computer-administered questionnaires; Skype; texting)

42. Additional Approaches under Development • Individualized Placement and Support • For Early Psychosis (e.g. Nuechterlein et al., 2008) • For Intensive Mental Health Service Users (Ellison, Fagan et al., 2013) • Supported Education/Career Development (Mullen et al., ; • Career Visions (Sowers); Based on the Self-Determination Career Development Model, (Wehmeyer et al., 1999) • Better Futures (Powers) • Achieve My Plan (Walker) http://www.pathwaysrtc.pdx.edu/index.shtml

43. Multisystemic Therapy for Emerging Adults MST-EA Adaptation of Multisystemic Therapy – 17-20 year olds with serious mental health conditions and justice system involvement

44. Collaborators Maryann Davis, Ph.D., William Fisher, Ph.D., Charles Lidz, Ph.D., Alexis Henry, Ph.D. University of MA Medical School, Center for Mental Health Services Research, Department of Psychiatry Ashli J. Sheidow , Ph.D., Michael McCart, Ph.D., Scott Henggeler, Ph.D. Medical University of SC, Family Services Research Center, Department of Psychiatry and Behavioral Sciences Sara Lourie, MSW., Anne McIntyre-Lahner, MS. Connecticut Department of Children and Families MST-TAY Team - North American Family Institute Thanks to the emerging adult participants and their social network members Funding for this research comes from the National Institute of Mental Health (R34 MH081374-01) and the National Institute of Disability and Rehabilitation Research (H133B090018) to PI Davis

45. Arrest Rate in Adolescent Public Mental Health System Users Davis, M., Banks, S., Fisher, W, .Gershenson, B., & Grudzinskas, A. (2007). Arrests of adolescent clients of a public mental health system during adolescence and young adulthood. Psychiatric Services, 58, 1454-1460.

46. Juveniles Adults • Antisocial peers • ↓ Parental supervision/monitoring • Unstructured time (school & afterschool) • Substance Use • Rational choice/distorted cognitions • Attachment to school, prosocial peers, family • Peers influence less • Parental influence lessened/indirect • Unstructured time (work) • Substance Use • Rational Choice/distorted cognitions • Attachment to work, spouse Malleable Causes of Offending and Desistance

47. Transition-Age Offenders with SMHCs • Simply addressing mental health needs found unsuccessful in reducing offending in adults • Wraparound approaches have had good outcomes in reducing antisocial behavior in youth with SMHC but is designed for children, not young adults

48. MST-EA Inclusion and Exclusion Criteria • 17-20 year olds with a diagnosed serious or chronic mental health condition • Recent arrest or release from incarceration • Living in stable community residence (i.e., not homeless) • Having involvement from family members is neither an inclusion nor exclusion criteria • Individuals who have children or are pregnant are not excluded

49. Standard MST (with juveniles, no SMHC) • Intensive (daily contact) home-based treatment delivered by therapists; one therapist/family caseload=4-5 • Promote behavioral change by empowering caregivers/parents • Individualized interventions target a comprehensive set of identified risk factors across individual, family, peer, school, and neighborhood domains • integrate empirically-based clinical techniques from the cognitive behavioral and behavioral therapies • Duration; 4-6 months 3-4 Young Adults work, and neighborhood domains with the best evidence for this age group 4-14 months

50. MST-EA Team • 3 Therapists • On-Site Supervisor • Off-Site Consultant • 0.2 Psychiatrist/Nurse Practitioner • Life Coaches (4, totaling 1.0FTE) • Full Team Caseload = 12