School Accommodations and Skill Building Are Key for Helping Youth Thrive After First-Episode Psychosis
Youth with early psychosis need help from clinicians to ease their transition back to school and work in order to truly recover.
Ethan is a 16-year-old who once earned As and Bs and had close friends in school. About a year ago, his grades dropped to Cs and Ds, he quit soccer, and his teachers noticed he was no longer making eye contact, was often talking to himself, and seemed suspicious of offers of help. He began refusing to go to school, claiming the Illuminati were following him; threw away his phone; and stopped leaving his bedroom.
During a one-week hospitalization, Ethan was diagnosed with schizophrenia and was started on antipsychotic medication. Afterwards, he began receiving care from a coordinated specialty program. Despite that, his return to school did not go smoothly. He continued to socially isolate himself and seemed suspicious of others’ intentions at school, was struggling to read, and took much longer to complete his schoolwork. He was falling behind.
It turns out that there is much that psychiatrists and other clinicians can do to help youth like Ethan with early psychosis transition back to high school or even college, according to presenters who recently spoke on the topic at the American Academy of Child and Adolescent Psychiatry’s 2024 annual meeting. The key is for clinicians to collaborate with schools to obtain accommodations, to assess youth’s academic and life skills, and to coach them to improve areas of weakness.
Such interventions are crucial because without them, high school–aged youth with psychosis tend to have lower attendance and poorer performance than their peers, explained Olivia P. Hamrah, M.D., a child and adolescent psychiatrist at MedStar Georgetown University Hospital. In addition, older youth with psychosis are more likely to withdraw from post-secondary education, negatively impacting their future career prospects.
Identify Needed Accommodations
A good first step for clinicians is to craft a 504 plan. This document lays out basic accommodations a student with a disability needs to better access the curriculum. Typical accommodations include providing alternatives to public speaking assignments, offering class notes in advance of a lecture, and identifying safe spaces where the student can retreat when uncomfortable.
Clinician involvement in the transition back to school is critical for youth after they’ve experienced early psychosis, said Olivia P. Hamrah, M.D. Without intervention, youth tend to have lower attendance in high school and poorer performance than their peers.
“It can be put together very quickly based upon the recommendation of a clinician” and by working with school support staff, Hamrah said. One drawback is that such plans provide little recourse or due process if they are not helpful for the student.
By contrast, an IEP, or individualized education plan, is more involved and is available only to students with a disability that interferes with their educational progress. Hamrah said a student like Ethan with schizophrenia would qualify on the basis of his emotional disability and could receive adaptive instructional materials, such as permission to record lectures, and academic changes, such as a reduced workload, substitute courses, and waived course requirements. In addition, a student with an IEP may qualify for a tutor.
Huma Baqir, M.D., adult, child, and adolescent psychiatrist at the University of California, San Diego, said that it’s important to engage in psychoeducation when working with postsecondary schools. “Help them to understand that this is someone who can do really well academically with the right support,” she said. “Youth with psychotic disorders have hope for recovery.”
One potential challenge is the lack of formal school-based services to help youth with psychosis make the transition after high school graduation. “The IEP makes an abrupt end after high school. It doesn’t travel with the student to college,” Baqir said. However, it does provide a starting point for reasonable accommodations for which the college student can advocate.
Youth with early psychosis have lower rates of accessing specialized support services compared with more mature adults with the same condition, said Huma Baqir, M.D.
Unfortunately, youth with early psychosis have lower rates of accessing specialized services compared with more mature adults with the same condition, Baqir said. Gaps in insurance coverage or access to specialized care may compound this, even for students who remain on their parents’ insurance plans. Such plans don’t always cover the services that are needed at college, and few colleges have psychiatrists onsite.
Assess Readiness Early
Baqir said that it’s also important to first assess a patient’s readiness to move out of their parents’ home based on their mastery of various domains. She uses a checklist that allows for realistic assessment of patients on the following skills, so they can tackle any deficiencies in future sessions:
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Knowledge of their mental health condition, diagnosis, and medications. Patients also need to understand how to obtain refills, the impact of substance use and sleep, how to use their insurance, and request their own health records when needed.
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Ability to self-advocate. Knowing the purpose of academic accommodations and how to ask for them in advance, the pros and cons of disclosing their psychiatric illness, and how to utilize the support of the disabilities office.
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Independent life skills. The ability to drive and remember to carry their driver’s license, knowledge of how to budget, grocery shop, and cook a few simple meals, manage personal hygiene, do laundry, manage their leisure time in a healthy way, set and respond to alarms, and check email regularly.
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Independent academic skills and executive functioning. The ability to track and prepare for projects, papers, and tests without help from their parents. Knowledge of which courses are needed to graduate successfully.
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Psychosocial functioning. The ability to manage chores, tackle problems with peers and roommates, make friends, and handle rejection when dating.
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Safety issues. Awareness of warning signs of relapse in their mental illness as well as knowledge of navigating social media safely, avoiding problematic substance or social media use, safe sex, and managing the stress of college life.
Baqir said it is critical to start these types of formal discussions of transition readiness at age 15 or 16—at least a couple of years before the young person plans to move out on their own. It takes a village: “Parents, guidance counselors, teachers, mentors, and coaches can also work with the student on readiness.”
Some students might ultimately opt to enroll in a two-year community college and remain at home rather than move immediately to a four-year university, Baqir said. “It’s also important to remember that the undergraduate trajectory might be longer, but students recovering from psychosis can absolutely be successful.
Education and Employment Specialists
Philip J. Thomas, M.Ed., a supportive education and employment specialist (SEES) with OnTrackNY, which provides early intervention for individuals with first-episode psychosis, said that recovery at its core cannot be measured solely by a decrease in symptoms of mental illness.
“It’s also about participants reaching and achieving their own goals, many of which revolve around school and work,” Thomas said. “Going to college and having a career significantly contributes to the quality of life for individuals we work with.”
Many individuals engaged in active treatment want to follow these paths, but treatment teams, families, and even the individual have doubts and often ask whether the individual is really ready for the next step. “One of the roles of the SEES is to believe in our clients’ readiness,” Thomas said. “All it takes is for someone to help them bridge the gap.”
In fact, SEES go to bat for the youth and collaborate with schools and employers to obtain accommodations. The SEES’ role also goes well beyond that by helping youth improve their life skills, such as learning to manage their time, budget, create a LinkedIn account, apply for a job, complete financial aid paperwork, engage in a mock interview, and even help with homework.
Research has shown that individualized placement and supportive employment programs can be twice as effective as other job programs for this population, Thomas explained. That’s because its services are tailored to the experiences, needs, and goals of each person supported. ■
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Psychiatric News
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Published online: 23 December 2024
Published in print: January 1, 2025 – January 31, 2025
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