Adele Martel

Teaching a Systematic Approach for Transitioning Patients to College: An Interactive Continuing Medical Education Program

ObjectiveThe purpose of this article is to determine the effectiveness of a hands-on continuing education program for practicing child and adolescent psychiatrists (CAPs) with a focus on best practices in transitioning psychiatric patients to college. The plan was to build on the unique knowledge and skill set of CAPs, use audience and facilitator feedback from prior programs to inform program content, structure, and format, and incorporate findings from the evolving literature.MethodsA 3-h interactive workshop was designed with an emphasis on audience participation. The workshop was divided into three main segments: didactics, whole group discussion/brainstorming, and small group discussion of illustrative case vignettes.ResultsImprovements and changes in knowledge, skills, and attitudes related to transition planning were identified by program participants. Quantitative feedback in the form of course evaluations, pre- and posttests, and a 6-month follow-up questionnaire indicate that the use of interactive teaching techniques is a productive learning experience for practicing CAPs. Qualitative feedback was that the discussion of the case vignettes was the most helpful.DiscussionThe use of a workshop format is an effective strategy to engage practicing CAPs in learning about and implementing best practices to support the transition of their patients to college and into young adulthood. Comprehensive and proactive transition planning, facilitated by clinicians, should promote the wellness of college-bound patients and help to reduce the potential risks in the setting of an upcoming transition.

Preparing and Training the College Mental Health Workforce

More than 20 million individuals are enrolled in 2-year, 4year, graduate, and professional degree-granting institutions in the USA [1]. We refer to this diverse mix of primarily young people as college students and the broad range of services designed to attend to their mental and emotional health as college mental health. College students constitute a growing and critically important population in need of evidencebased mental health services [2]. The population is diverse in age, life experience, mental health history, socioeconomic status, and ethnicity. Students range from 18-year-olds entering 2or 4-year postsecondary education programs directly out of high school to older students heading to college after serving in the military, raising families, or working for several years. Other students choose to pursue advanced degrees, such as in law or business.Within these broad groups are special populations, such as students with chronic medical or mental health disorders, athletes, international students, and first-generation students. Each group brings to campus distinct strengths, vulnerabilities, and needs [3]. As Sood and Martel state, “Acculturation issues, differences in help-seeking behaviors, worries about families left behind, difficulties managing social situations, lack of support networks, discrimination, and post-traumatic stress reactions are just some of the concerns complicating an already stressful life transition” ([4], p. 70). Over the past 25 years, many factors have contributed to the increase in the number and diversity of college students, as well as their clinical needs [5]. For examp le , va r i ous i t e r a t i on s o f t he G . I . B i l l (Servicemen’s Readjustment Act of 1944) encourage, allow, and support veterans to return to school [6]. The percentage of enrolled minority students has increased with US population trends and various special programs [7]. Improvements in identification and early intervention of mental health problems in young children and adolescents allow many to attend college who were previously unable to do so [5, 8]. The Americans with Disabilities Act supports students with various physical, learning, and emotional disabilities to seek postsecondary education experiences [9]. Three-quarters of mental illnesses begin before age 24 [10], and mental illness, including substance abuse disorders, contribute the greatest proportion of disease burden in young people aged 10–24 years around the world [11]. The late maturation of the prefrontal cortices provide a neural basis for beginning to understand the impulsivity and risk-taking behaviors characteristic of transition age youth and young adults [12, 13]. The complex interrelationships among neurologic, psychological, cognitive, interpersonal, and psychopathologic development all contribute to their vulnerability. For youth with mental illness, the transition from child and adolescent to adult systems of care can add risk to vulnerability because the adult system is not generally trained to deal with the complex developmental issues that young adults present [14]. Copious data link dropping out of college with health, mental health, social, and economic problems later in life [15, 16], such that increasing college retention may itself be viewed as an important public health intervention. * Michelle Goldsmith mgoldsmi@stanford.edu

A Model CSMH Curriculum for Child and Adolescent Psychiatry Training Programs

Child and adolescent psychiatrists (CAP) care for high school students preparing to enter college. They also may continue to see students while on school vacations and may care for college students in various settings (emergency room, inpatient hospital unit, private practice, college student health service, or counseling center). As increasing numbers of students with mental health diagnoses pursue secondary education, CAP need to be knowledgeable about campus systems of care, principles of transition, and privacy and educational laws affecting college students. This article describes an informal needs assessment of general CAP members of the American Academy of Child and Adolescent Psychiatry and details the results of a survey of CAP program directors on training opportunities in college student mental health (CSMH). The authors present a sample curriculum for a clinical rotation in CSMH, as well as providing ideas for core didactic lectures, and proposing the development of online resources to reduce the burden of creating new lectures and standardize experiences among training programs.

Successful Transition to Young Adulthood with Mental Illness: Common Themes and Future Directions

The transitional age youth (TAY) demographic (as defined in the Preface), representing a unique developmental period in life, has recently garnered the interest of clinicians, researchers, educators, governmental agencies, and policymakers. Historically this age group has been considered late adolescents and early adults rather than a subgroup of its own. The implications of categorization are significant in terms of understanding of these individuals and the ability to support them. Attention to this group has been prompted by increasing the knowledge base in neurodevelopment, epigenetics, epidemiology, prevention, overall young adult health, and functional outcomes, particularly in regard to mental health. Addressing the mental health needs of TAY has become a national priority and there is increasing recognition of the potential for productive interventions in this complex and important developmental period. Mental illness may present in childhood, adolescence, or young adulthood, with influences on psychosocial, emotional, and brain development that vary with the age and context of illness presentation. Temperament and genetics are baseline factors contributing to individual responses to life experiences. Developmental experiences can be protective and build resilience or convey risk to expression of illness or to negative outcomes. In combination, these factors influence developmental trajectories and developmental branch points, contributing to variable expression of health and illness. The authors in this issue have identified many common themes. One overarching theme is the importanceof culturally competent care. There continue to be health disparities related to race, ethnicity, and other diversity. Culture influences howmental health is defined and viewed by individuals. TAY are often in transition, which can introduce a variety of cultural attitudes, challenging familiar normsand introducing, at times, anunanticipated levelof stress. It is imperative todevelopmore sophisticatedawarenessof ourown ethnocentric views and possible ethnocentric graduate medical education training. It is equally imperative to orient training of child and adolescent psychiatry and general psychiatry residents toward cultural understanding within the TAY population. Rivas-Drake andStein (this issue) state it well: “Researchers and practitionersmust strive to build their capacity to keep pace with the demographic shifts of the US youth population.”

Helping Patients and Families Navigate the Transition to College: Common Themes, Lessons Learned, and Best Practices

The clinical cases in this book serve to highlight a number of strategies and themes that can be used to guide the development of best practices in transition preparation and planning for youth with mental health conditions headed to college. Mental health care transition, in this context, demands a team effort involving the young person, his/her family, high school personnel, treatment providers on both sides of the transition, and other designated supporters. A developmental perspective is key to the process, acknowledging the importance of the young person in decision-making and recognizing that age-appropriate support and structure before, during and after the transition makes sense for many student/patients. Clinicians need to assess the readiness of patients for the transition to college across multiple domains of function and should be prepared to raise difficult issues such as mental stability, the stresses inherent in what is usually considered a happy milestone, alternative post-secondary options and paths, over-reliance on parental and school supports, and the need for ongoing care once on campus. Comprehensive and well-communicated plans for continuity of care, including relapse prevention plans and services through the school’s ODS, are an important aspect of transition preparation and planning. Mental health practitioners have important roles to play in facilitating safe and effective transitions of their patients to college.

“This Beer Should Do the Trick!”: Heading to College with Social Anxiety Disorder

Social Anxiety Disorder may adversely impact transition to college. Alcohol and cannabis can be misused or abused in an attempt to self-medicate symptoms. Academic underachievement is common due to lack of self-advocacy, fear of public speaking, and avoidance of classes. This chapter describes the case of a young woman diagnosed with Social Anxiety Disorder and Major Depression Disorder prior to college matriculation. While her symptoms were relatively stable prior to starting college, she experiences a relapse of both anxiety and depressive symptoms in the context of disrupted treatment. This contributes to misuse of alcohol as well as declining academic achievement. Discussion focuses on the need to adequately prepare the patient and family for the transition to college through psychoeducation, establishing a treatment team on or near campus, anticipating potential difficulties with academics and social relationships, and developing a plan for accessing campus resources and supports. Other topics discussed include introversion, social maturity, and developmental readiness for college.

The Practice Gap in Health Care Transition: Focus on Young People Heading to College with a Mental Health Condition

Planned health care transition for young people with special health care needs, including those with emotional, behavioral, and developmental disorders, has been deemed a health priority both here in the U.S. and abroad. However, gaps in health care transition services for adolescents and young adults continue to exist. Youth headed to college with pre-existing mental health conditions are among those in need of transition preparation and planning services. When compared to their peers without mental illness, these students face additional challenges when transitioning to college. They must have some understanding of how their illness might impact functioning in the college environment and what supports they need to aid academic and social success. They are expected to manage their illness more independently, advocate for themselves, develop relationships with new treatment providers, and navigate a new system of care. In this chapter, the definition and goals of health care transition are described. Then, by looking at the prevalence of mental health disorders in the college-age population in conjunction with recent college enrollment statistics, findings from developmental psychopathology, and survey data of incoming freshman, the scope of the need for mental health care transition services for college-bound youth is highlighted. Knowledge of normal child, adolescent, young adult, and family development, the principles of the systems of care model, tenets of educational transition planning, and anticipatory guidance, along with clinical experience and expert consensus, inform best practices in mental health care transition planning.

Adaptation of Pediatric Health Care Transition Guidelines for Use with Youth Heading to College with Mental Illness: Building a Toolkit

Health care transition preparation and planning for youth heading to college with mental health conditions should be integrated into clinical practice in a way that addresses the developmental and treatment needs of youth, supports their families during the transition, and is practical and sustainable for clinicians. In this chapter, health care transition planning, as described in the 2011 clinical consensus document by the American Academy of Pediatrics, the American Academy of Family Physicians, and the American College of Physicians, and the Six Core Elements of Health Care Transition have been adapted and elaborated upon for college-bound students with mental health conditions. A set of office-based transition tools is provided for use in routine practice and includes a Transition Readiness Assessment and Action Plan for Youth Heading to College with a Mental Health Condition, sample transfer of care plans, a sample emergency care plan, and a sample office transition policy. The differences between and value of a Mental Health and Medical Summary versus a Transition Portfolio are noted. Characteristics of this cohort of students, the academic and social demands of college, and features of the college application process have been taken into consideration in the development of this toolkit. Using a structured transition process on a routine basis should allow for more comprehensive transition planning and potential transition success.

“Anxiety Galore”: Transition to College with Generalized Anxiety Disorder

Generalized Anxiety Disorder is a common mental health concern that often begins in adolescence and, unfortunately, persists into adulthood. Symptoms may fluctuate based on stressful life events, such as transitioning from high school to college. This chapter presents the case of a young man who has struggled with symptoms of anxiety since childhood and describes how his symptoms cause impairment as he makes the transition from high school to college. It details how to best help individuals with anxiety prepare for the start of college while also navigating the college mental health system and optimizing the appropriate services and supports. Finally, as alcohol and drugs can be common, yet unhealthy coping mechanisms in this population, there is discussion of strategies to optimize treatment adherence and reduce temptation to misuse alcohol and benzodiazepines.