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
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
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
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
Major causes of disease burden in Disability Adjusted Life Years
IN THE WORLD
Males
Females
Males
Females
World
Leading Neuropsychiatric Disorders causing DALYs:
High Income
Unipolar Depression* (7.9-9.9%)
Schizophrenia (4.2-5.3%)
Bipolar Disorder (4/1-5.1%)
Europe
Within top 6 causes of DALYs
in 15-24 yr olds in the world
Americas
15-19 Year olds
HIV, TB, malaria
Other communicable diseases
Neuropsychiatric disorders
20-24 Year olds
Maternal conditions
Other non-communicable diseases
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
Developmental Changes Underlie
Abilities to Function More
Maturely
Complete schooling
& training
Contribute to/head
household
Obtain/maintain
rewarding work
Develop a
social network
Become financially
self-supporting
Be a good citizen
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.
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.
Youth with SMHC
Struggle as Young Adults
Functioning among
SMHC in Public Services
18-21 yr olds
Complete High School
23-65%
Employed
46-51%
Homeless
30%
Pregnancy (in girls)
38-50%
Multiple Arrests by 25yrs
44%
General Population/
without SMHC
81-93%
78-80%
7%
14-17%
21%
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
Functioning in Adults with Psychiatric Disorders; Young Adults
Different from Mature Adults
% of Respondents
60
55
18-30 yr olds
50
40
33
33
30
20
10
24.2
21.8
18.3
29.5
18.3
8.9
2
0
*2 (df=1)=31.4-105.4, p<.001
** 2 (df=1)=5.5, p<.02



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.
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.
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)

Typical Social Development
Friendships become more complex, involving mutuality,
intimacy, and loyalty.
Peer relationships are of PARAMOUNT importance.
Peer context changes; school to work transition
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
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?
Typical Sexual Development
Life-impacting and safety issues
Address sexual orientation
New types of intimacy
Different roles in peer group
Psychosocial Development in Those
with Serious Mental Health
Conditions

Research limited to adolescence – but implications hold for
emerging adults with histories of SMHC
 Individuals will vary in their level of development
 Individuals may be more mature in one area than another
Transitions RTC
Typical Changes in Family Relations
Young people and parents must adjust to the growing need
for independence while remaining emotionally related.
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
Developmental Implications
Supports need to be developmentally
appropriate
Transitions RTC
Developmental Implications
Support
Increased Self
Determination
Make Decisions
Head a
household
Transitions RTC
Financially
self-supporting and
responsible
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
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.
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
Transitions RTC
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
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
F&C/CHIP (n=382)
Primary Care No Primary Care
Disabled/Foster Care/Limited Coverage (n=794)
No Recent Disenrollment Recent Disenrollment
(n=567)
12.5%
(n=168) 44.6%
Age <22.6
Age <20.1
(n=85) 61.2%
Age >22.6
Age >20.1
(n=76) 82.9%
(n=53)
50.9%
(n=227)
40.1%
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

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
The current evidence base
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)
Employment Intervention Demonstration Program
Supported Employment Randomized Trial
1.00 – Any Competitive Employment
.90 –
Control
.80 –
SE
.70 –
.60 –
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.
.50 –
.40 –
.30 – Ages 18-24
Ages 25-30
Ages 31+
EVIDENCE BASED
TREATMENTS IN
DEVELOPMENT
Most in feasibility research stage
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
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)
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

Transition Age
Youth Quickly Lost
from Treatment
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
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
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)


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 SelfDetermination Career Development Model,
(Wehmeyer et al., 1999)
◦ Better Futures (Powers)
◦ Achieve My Plan (Walker)
http://www.pathwaysrtc.pdx.edu/index.shtml
Multisystemic Therapy for Emerging Adults
MST-EA
Adaptation of Multisystemic Therapy –
17-20 year olds with serious mental health
conditions and justice system involvement
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
Arrest Rate in Adolescent Public Mental
Health System Users
All Males
Males Arrested Last Yr
0.60
All Females
Females Arrested Last Yr
0.50
0.40
0.30
0.20
0.10
0.00
13
14
15
16
17
18
19
Age
20
21
22
23
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.
24
Malleable Causes of
Offending and Desistance
Juveniles
Antisocial peers
↓ Parental
supervision/monitoring
Unstructured time (school
& afterschool)
Substance Use
Rational choice/distorted
cognitions
Attachment to school,
prosocial peers, family
Adults
Peers influence less
Parental influence
lessened/indirect
Unstructured time (work)
Substance Use
Rational Choice/distorted
cognitions
Attachment to work,
spouse
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
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
Standard MST
(with juveniles, no SMHC)





Intensive (daily contact) home-based treatment
delivered by therapists; one therapist/family
3-4
caseload=4-5
Promote behavioral change by empowering
Young Adults
caregivers/parents
Individualized interventions target a comprehensive
set of identified risk factors across individual, family,
work,
and neighborhood
peer, school, and
neighborhood
domainsdomains
integrate empirically-based clinical techniques from
the cognitive behavioral and behavioral therapies
with the best evidence for this age group
Duration; 4-6
months
4-14
months
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
MST for Emerging Adults

MST-EA Elements
◦ Treatment of Antisocial Behavior
◦ Mental Health, Substance Use, and Trauma
Interventions
◦ Social Network
◦ Housing & Independent Living
◦ Career Goals
◦ Relationship Skills
◦ Parenting Curriculum
MST-EA
MST-EA Life Coaches
 Young adult who can relate
 2, 2hr visits/week, 1 hour curriculum, 3
hours fun
 Reinforces relationship skills in natural
environment
 Curriculum topic chosen by client and
therapist
 Supervised by clinical supervisor
 Vocational component being compared to VR
services
Treatment Retention


Incomplete
Tx minimum
# weeks of
treatment =
16
Complete Tx
ranged from
4 to 12
months
Restrictive
Placement
13%
Engagement
Lost
13%
Mutual
agreement
12%
Completed
Treatment
(goals met &
sustainable)
62%
Recidivism Arrests 18 months post-entry



1. Post Tx arrests
did not result in
placements
2. Total Charges in
each time period =
7
3. Most serious
charges:
◦ During MST-EA =
Larceny
◦ Post MST-EA =
Larceny, Drugs
near a prohibited
place
Post Tx, 2
No
Arrests
During or
Post Tx, 10
During Tx,
4
Continue
Tx, 3
Disrupt Tx,
1
RECIDIVISM
-SELF-REPORTS
Self-Reported
# Different Types of Crime
7
6
5
4
3
2
1
0
Baseline
-1
6 months
12 months
Mental Health Symptom Intensity (BSI)
Symptom Intensity
35
1.6
30
1.4
1.2
25
1
20
0.8
15
0.6
10
0.4
5
0.2
0
0
Baseline
6 months
12 months
NOTES:

Only one individual was hospitalized
Mean Symptom Intensity
Mean Number of Symptoms
Number Symptoms
SUBSTANCE
USE
Majority of the 25
cases to date (84%)
have presented in
need of treatment
for substancerelated problems
Positive Urine Screens
100
90
80
75%
70
64%
60
50
40%
40
30
20
10
0
Baseline
6 months
12 months
NOTES:

22 + screens: 21 THC, 3 opiate, 1 cocaine
Vocational/Educational Outcomes
71% of months working or
schooling/training
 81% of participants 1+ months paid
employment

Context:
• 50% employed post high school 18-24 yr olds w SMHC (Wagner &
Newman, 2012)
• 50% competitively employed 18-24 yr olds in vocational support
programs (Burke-Miller et al., 2012)
• <33% youth exiting juvenile corrections obtains work
• Juveniles receiving MH services about half as likely to be
employed as delinquents without MH services (Bullis & Yovanoff ,
2006)
Working by LC Condition
VocLC
BasicLC
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
Baseline
During Tx
Post Tx
Common Themes




Youth Voice; all developing models put youth front and center,
and provide tools to support that position
Involvement of Peers supports; several interventions try to
build on the strength of peer influence
Struggle to balance youth/family; delicate dance with families,
no clear guidelines
Emphasize in-betweeness; simultaneous working & schooling,
living w family & striving for independence, finishing schooling
& parenting etc.
Transitions RTC