Essential Domains in Transition Planning and the Roles of Various Constituents

Abstract

The child and adolescent psychiatrist (CAP) has a unique role in helping choreograph the transition to college of youths with special needs. In collaboration with the youth and his/her parents, school personnel, and other mental health providers, the CAP can help focus the youth’s skill development and familiarity with a body of information needed for a successful transition to college. The skills and information needed for a smooth transition can be organized into six essential domains: Health Condition Knowledge and Skills; Self-Advocacy Knowledge and Skills; Independent Life Skills; Psychosocial Development; Academic Skills and Executive Function; and Anticipatory Guidance. The purpose of skill development is to improve the youth’s independent functioning prior to matriculation at college, so that the youth can handle the demands of college life, while maintaining treatment regimens and healthy living. Possessing specific information about the college system of care, as well as anticipating some of the socioemotional challenges of life on a college campus are also essential to emotional stability and relapse prevention. Parents, providers, and the transitional age youth, all, have specific tasks to carry out to assist with a successful and healthy move to college.

Appendices

Chapter Appendix

• Readiness Domains and Sample Tasks for Youth with Mental Health Needs Transitioning to College (1 page)

• Sample Transition Preparation and Planning Tasks Assigned to Key Stakeholders when Youth Heading to College with a Mental Health Condition

• Patient Tasks (1 page)

• Parent/Guardian Tasks (1 page)

• Child and Adolescent Psychiatrist and/or Other Mental Health Professional Tasks (1 page)

• Launching Our Patients to College (“Reprinted with Permission from the American Academy of Child and Adolescent Psychiatry, © All Rights Reserved, 2017”) (4 pages)

Readiness Domains and Sample Tasks for Youth with Mental Health Needs Transitioning to College

Health Condition Knowledge and Skills	Self-Advocacy	Independent Life Skills	Psychosocial Development	Academic Skills and Executive Function	Anticipatory Guidance
– Identifying and monitoring main symptoms and reaching out for help when needed – Managing stress – Healthy lifestyle – Taking medications as directed and obtaining refills in timely fashion – Keeping medical and mental health appointments – Understanding impact of poor sleep, poor diet, lack of exercise, use of drugs and alcohol, poor medication compliance on risk of relapse – Signing medical releases and permissions for medication and medical interventions – Deciding about emergency contacts and possible parental access to treaters	– Participate in IEP meetings in high school – Understanding laws: IDEA, ADA, FERPA, HIPAA – Contacting Office of Disability to obtain accommodations – Informing profs of accommodations – Setting up support system on campus – Communicating with former or ongoing treaters from home – Recognizing need for and accepting help in a timely fashion, ideally BEFORE crises arise – Advocating for self with professors, peers, roommates	– Managing schedule of classes, assignments, jobs, and social activities – Handling life tasks (sleep, getting up, eating, meds, hygiene, clean-up, finances, laundry) – Making and keeping appointments with tutors, counselors, profs, physicians, disability office – Balancing relationships with home (when to go home? How often? Stay how long?) – Managing bills/credit cards – Arranging transportation from home to school	– Learning to drive – Holding down a job or regular volunteer job – Coping with others with different lifestyles and values – Taking courses out of comfort zone – Trying out new roles with friends and family, as well as new college acquaintances – Coping with the exposure to politics, religions, philosophies, and ways of living that may challenge the status quo – Handling exposure to treatment interventions which may challenge current mental health treatment	– Handling multiple simultaneous demands – Breaking down big assignments into manageable tasks – Increase use of primary source materials requiring interpretation and synthesis – Managing greater cognitive demands – Writing longer complex papers – Synthesizing large body of information – Evaluating ideas – Speaking up in class	– Coping with roommate hassles and expectations – Dating and intimacy challenges – Living with people of varied cultures, religions, races, genders – Managing challenges to academics: sex, alcohol, drugs, porn, social networks, video games, lack of sleep, intense relationships, over-commitment – Handling legal access to alcohol – Dealing with adult legal system – Signing contracts and leases – Practicing stress management (i.e., yoga, meditation, exercise, contact with nature, art, music)

Sample Transition Preparation and Planning Tasks Assigned to Key Stakeholders when Youth Heading to College with a Mental Health Condition

	Before College Selection Process	During College Selection Process	After College has been Selected	Post-Matriculation
Patient Tasks	– Identify types of colleges desired – Identify preferred locations – Identify how often come home – Identify biggest hopes/worries about going to college – Identify biggest hopes/worries about being away from home – Identify HS requirements needed for most colleges – Give best effort on SAT/ACT and HS classes, and test prep courses – Comply with and participate in mental health treatment as outlined below – Attend IEP or 504 meetings – Complete cognitive/educational testing if recommended to obtain accommodations for national tests and college classes – Work on healthy choices and independent life skills prior to college (i.e., drive a car, do laundry, manage credit or debit card, get a job, do basic cooking, seek help from others, good medication compliance, limit drug and alcohol use, get exercise)	– Check out whether college has a disability center and can offer accommodations – Check out available mental health services on campus as well as off campus – Check out insurance coverage at college; whether home insurance can be used or new insurance needed – Check out availability of writing lab/tutors/support services/mentors for ASD, ADHD, LD students, etc. and if part of tuition – Check out transportation needed to get to mental health treatment – Check out if special interest groups/support groups are available (i.e., LGBT, AA/NA campus meetings, sex abuse survivors, multicultural groups, religious groups, political activism, mental health advocacy groups)	– Obtain accommodations with disability center – Identify mental health treaters at college, in community, or at home – Clarify insurance coverage – Sign releases for old and new treaters to communicate with parents – Sign releases for home CAP and therapist to communicate with treaters and other important personnel on campus – Attend special programs for new students and/or special interests – Clarify how to get meds (on-campus MD via health center, community psychiatrist call in to local pharmacy, at home provider calls pharmacy, parents mail meds) – View college website with parents and CAP to become familiar with locating services on campus	– Sign releases if not done – Meet with disability counselor and advisor(s) – Distribute accommodation letters to professors and learn attendance policy for each class – Introduce self to resident advisors and/or student advisors in dorm – Set up schedule for meals, exercise, mental health appointments, tutors, etc. – Secure location for meds in living setting, and set up system for daily med reminders – Set up appt(s) with new treater(s) and check in with old treater(s) if needed – Identify who to call for any after-hours emergency and provide number to parent, trusted friend, and roommate, if appropriate – Review budget with parents, if appropriate
Parent or Guardian Tasks	– Help child apply for accommodations for SAT/ACT through school – Identify hopes and worries about child going to college – Identify possible financial contributions of parents – Clarify mental health coverage for child if out of state – Identify how often would child like to come home – Clarify any non-college family responsibilities that parent expects of child – Support and participate in child’s mental health treatment – Encourage age-appropriate independence and healthy living practices in child (i.e., manage money, setting and waking up to alarm, medication compliance, getting driver’s license, manage stress in healthy ways, get job or do volunteer work, good personal hygiene, doing own laundry) – Arrange for child to have cognitive testing done or repeated if not done within 2–3 years of college matriculation	– Assist child with above tasks – Check out insurance coverage at college and whether home insurance can be used or new insurance needed; parent may find that taking out the student insurance, in addition to parent’s insurance, may help child with better mental health coverage for local hospitals and providers – Check out possible transportation costs to and from school, considering how many trips to and from school are anticipated – Check proximity and quality of nearby general hospitals and whether there are available emergency psychiatric services in the hospital – Attempt to develop a reasonable budget for child based on family funds and possible costs for college expenses and transportation to school, prior to meeting with child and provider	– Assist child with above tasks – Help child apply for accommodations with disability center if one available – Clarify insurance coverage and consider paying for college student insurance if provides access to local treaters – Review with child basic consumer information and legal issues (i.e., signing up for credit cards, signing leases or loan agreements, hosting parties where minors are drinking alcohol or using drugs, driving under the influence, date rape, transporting drugs of abuse, etc.) – Discuss with child what they (parents) expect of their child in order to have them (parents) pay for education: treatment compliance; weekly check-ins; pass all classes; seek help when needed; respect budget limits; practice healthy living	– Assist child with above tasks – Visit counseling center and disability center with child if child agrees – Inquire about possible emergency services that may be available via counseling center and presence of a student of concern committee – Obtain names and contact information for child’s on-campus mental health team, treating psychiatrist, resident advisor, student advisor, roommates or floormates – Attend first appointment with new mental health provider with child’s permission, if appropriate – Notify treaters and/or college personnel (student of concern committee) of any concerns about their child’s mental status changes or level of functioning
CAP and/or Other Mental Health Professional Tasks	– Assist parent and patient with their tasks noted above – Discuss patient’s diagnoses with parent and patient, and treatments needed to improve symptoms and outcome – Discuss factors which increase risks of relapse/worsen symptoms and factors which may be protective or decrease risks – Discuss meds (i.e. names, purpose, side effects, how best taken, security needed with meds when away from home, how to obtain refills, when to call CAP with issues) – Discuss drug and alcohol use, impact on mental health, interactions with meds, risks (and possible experienced benefits) involved in drug/alcohol use – Discuss sexual/reproductive health and possible impact of diagnoses and medications on sexual experience and fetal health if taking medications or using alcohol and/or illicit substances – Discuss with patient and parent recommended therapeutic supports needed in college	– Assist parent and patient with their tasks noted above, including review of budget and parent/patient financial expectations – View websites of one or two possible college choices with patient and parents to help them locate counseling services, medical services, disability center, academic supports, and after-hours emergency services or emergency process – If patient plans college out of state, check in with your malpractice provider about coverage and HIPAA issues if using telepsychiatry to continue treating patient – Clarify with patient your preference (yes or no or joint with college treater) about continuing to treat patient when in college; discuss rationale (distance to college, disease severity, h/o lethal behaviors, availability of appropriate treatment on/near campus, self-care abilities)	– View college’s website with patient and parent to help them locate counseling center info and/or disability center info, and what to do if after-hours emergencies – Assist parent and patient in deciding following: – Student’s allowance and what can money be spent on – Grades expected to remain at college – Grades expected for parent to pay for college – How often come home – How often parents visit – How often communicate – Discuss transition to college and possible issues (roommate hassles, social pressures, drug/alcohol use, dating/sex, how to seek help, pressure to share meds, etc.) – Contact new mental health treater if identified and coordinate care; clarify with patient and parent who is in charge during holidays and summers – Contact heads of counseling and disability services	– Check in with patient to see if they believe they can work with on-campus mental health team; make changes early on if poor fit; indicate to patient that you are going to check in with parents and current treatment team after a month – After first month of college contact members of new mental health team, including psychiatrist, to make sure that patient is attending appointments – After first month of college check in with parents and with current treaters to see if they have any questions or concerns about current services or emergency plans that have been put in place – If psychiatric management is shared with home psychiatrist and college practitioner, check in with patient during visits home and during vacations; coordinate care with college practitioner

Launching Our Patients to College

Originally published in AACAP News 2014;45(5):193–94. Reprinted with permission from the American Academy of Child and Adolescent Psychiatry, ©All Rights Reserved, 2017.

• Vivien Chan MD,
• Jennifer Derenne MD,
• Adele Martel MD, PhD &
• Patricia K. Leebens MD 

At any given time in our practice, we have adolescent patients visiting colleges, applying to universities, entering post-secondary education, and leaving home. Preparing for college success is a process that starts, ideally, much earlier. The child and adolescent psychiatrist can play an active role in helping patients plan and prepare for these transitions.

Post-secondary Education Options

Many post-secondary options exist. Students with special needs sometimes consider going to technical, vocational, or two-year community colleges. Community college can be a stepping-stone toward attaining a bachelor’s degree. Four-year colleges vary in size and diversity of student body, fields of study, geographic location, part-time study options, and a mix of graduate degrees offered. Paths to success without launching directly to college include volunteering, entering the work force, taking a “gap” year, and going abroad. Incorporating regular clinical assessments with personalized discussions of pro et contra are important tasks for the child and adolescent psychiatrist. For example, attending college locally while living at home can gradually increase independence in life skills and allows local support and medical relationships to continue. Community college education may allow for a more flexible curricular approach and the ability to work part-time. Transferring to a new campus after attending community college can offer more incremental change but may be problematic, especially for patients with limited social abilities, as making new friends where peers have already resided for 2 years can be difficult. Campus-specific “bridge” programs are designed to facilitate transition from high school to college. Some programs are for any transitioning student while others are by invitation-only, designed for special populations (e.g., first-generation college, disadvantaged backgrounds, at-risk, academically underprepared, autism spectrum) (U.S. Department of Education website). Each college-bound patient and family should consider all viable options given the young person’s mental health needs.

Disability Laws After Grade Twelve

Parents and patients need to be prepared to identify and document special needs and to expect changes from previous levels of support. After graduation from high school, the Individuals with Disabilities Education Act (IDEA) , which specifically directs funding to local school districts for students with disabilities, no longer applies; individualized education programs (IEPs) do not continue through college. Instead, emotional, academic, and physical needs are treated as disabilities that require workplace accommodations under Section 504 of the Rehabilitation Act (when federal funds are received by the institution) and the Americans with Disabilities Act (ADA) which extends the mandate of Section 504 beyond recipients of federal funds. At the federal level, these disability laws are enforced by the Department of Justice and the Office for Civil Rights, respectively.

Students are discouraged from making individual negotiations with professors about academic needs for chronic conditions. Patients who desire any type of accommodation, like extended time, isolated testing, or special housing, must self-identify at their college disability office. Whether called “Office of Student Support” or “Disability Services Center,” this office ensures campus compliance to ADA and Section 504. Practitioners can help patients by working on self-advocacy skills, investigating how and when patients need to register, discussing the need for updated neuropsychological assessments or psychological testing, and providing the appropriate documentation for requested accommodations.

Mental Health Services on Campus

Most campuses, large and small, offer counseling services. Learning about resources available for psychotherapy and psychiatric needs, fees and limits to services, ease in accessing care and managing prescriptions, and availability of specialty providers (for more complicated diagnoses) is essential before transition. Some staff personnel designated as “counselors” may not be mental health professionals (e.g., academic, housing, financial, or disability counselor). Also, registering at one unit or building at college may mean just that—registering for one supportive service. While some campuses highly coordinate services for individual students, this sophisticated level of management should not be expected. Patients and families need to be guided early in their college search to include availability of appropriate psychiatric services as a “deal breaker” for college choice.

Safety on Campus

As national attention has increased about safety and danger at college, many campuses have developed a multidisciplinary team comprising deans and professors, legal staff, campus security, and health and counseling staff who meet to review at-risk students. While the name of this team may vary (“behavioral intervention,” “crisis,” or “consultation” team), risk management meetings occur regularly to discuss and assist these students. At some campuses, students may be unaware that they are reviewed, and at others, affected students are directly involved. For serious concerns about a patient, it may take a few phone calls or Internet links by a community provider to identify this resource. Parents should be made aware of this resource as well.

Federal Privacy Laws

An investigation following the Virginia Tech incident in 2007 (www.oig.virginia.gov/documents/VATechRpt-140. pdf) found overly rigid and individual interpretations of privacy laws. Medical professionals are familiar with the Health Insurance Portability and Accountability Act (HIPAA) . The Family Educational Rights and Privacy Act (FERPA) governs the privacy of educational records at institutions which receive federal funds. Essentially, these laws protect privacy while permitting disclosure when necessary and in the case of emergencies. For example, under FERPA observations by campus personnel of aberrant behaviors can be shared with appropriate others. The overlap and interpretation of HIPAA, FERPA, and state laws on campus is complicated. Further guidance from the U.S. Department of Education has been published (U.S. Department of Education website).

Transition Planning

When anticipating a transition, it is helpful for the adolescent psychiatrist to have a clear sense of treatment goals and safe practice limits. Useful discussions include knowing and talking about the diagnosis, assessing mental stability during the college application process, and determining ongoing treatment needs. Establishing a transition plan is crucial. If remaining with the current psychiatrist, review the frequency of future appointments. If attending college at a distance, clarify the physician’s opinions of phone appointments, texts, and emails, and practice of telemedicine across state lines (pending medical license and malpractice carrier regulations). Transfer of care to a new physician also takes planning, and determining who is “in charge” of treatment for shared cases, especially for unstable patients or during holiday breaks is critical. Ensuring that appropriate authorizations for communication exist in advance decreases barriers when urgency arises. Creating a portable healthcare summary, preferably a joint effort by the patient, physician, and family, is a very valuable way for health communication to be conveyed.

Sample Transition Checklist

Middle School

• Review the need for a 504 Plan or an IEP and continuing one through high school

• Review socialization, interests, and hobbies (foundations now prime for later success)

• Discuss responsibility for basic ADLs (like grooming, sleep hygiene, nutrition, personal electronic use)

Early High School (Grades 9–10)

• Based on ability, begin exploring career goals and academic interests

• Discuss the diagnosis and impact of the condition on functioning; explore patient’s knowledge of diagnosis

• Discuss the differences between high school versus higher education (class sizes, time spent in class, independent study, amount of unstructured time)

• Review the differences in types of higher education (differences in degree, duration and types, public vs. private institutions, in-state vs. out-of-state, or international)

• Update testing (typically 3-years current) required to support accommodations for entrance examinations and disability services on campus

• For students with special circumstances, look for college “bridge” programs

Late High School and After Graduation

• Review post-secondary education choices with attention to available mental health resources on campus; specifically, navigate websites with patients and parents

• If a high degree of support is currently used for academic function, explore ways to duplicate support on campus

• Practice instrumental ADLs (like managing medication, shopping, cooking, tracking finances, scheduling and keeping appointments, driving, using public transportation

• Work on a portable healthcare/psychiatric summary and/or transition “portfolio”

• Discuss changes (or not making changes) to treatment in anticipation of transition

Managing the Transition

In addition to typical developmental issues, such as wishing for a “fresh start” by abandoning prior diagnoses, sharing space with a roommate, developing intimate relationships, homesickness, and using drugs and alcohol, attention specifically to mental health care during the college transition can smooth the way for success. For those interested in further resources, AACAP Facts for Families specific to college-bound patients are newly available (#111, 114, and 115) and educational programs are offered at the AACAP Annual Meeting each October.

References

• Commonwealth of Virginia. www.oig.virginia.gov/documents/VATechRpt-140.pdf

• U.S. Department of Education. www2.ed.gov/about/offices/list/ovae/pi/cclo/brief-1-bridge-programs.pdf

• U.S. Department of Education. www2.ed.gov/policy/gen/guid/fpco/doc/ferpa-hipaa-guidance.pdf

• U.S. Department of Education. www2.ed.gov/policy/gen/guid/fpco/brochures/postsec.pdf