InvisALERT Solutions – ObservSMART

Designing Integrated Services for Adolescents: One Agency’s Experience

Addressing the mental health needs of teens in a clinic setting offers a unique set of challenges. Adolescent clients can strain the assumptions and framework of traditional mental health services in a number of ways: they have a developmental imperative to separate from parents and adult authorities, yet are often told to go to treatment by families and schools. They are neither autonomous adults, nor children fully dependent on their families, and above all they value and respond to peers. Minority teens in low income urban environments struggle with additional burdens such as community violence, enticement of gang belonging, limited access to resources, and the impact of racism on identity formation and self-esteem. This article describes our experiences designing a service model geared specifically toward the complex needs of minority teens living in a low-income area. A key factor in establishing this model was the request from members of the agency’s Consumer Advisory Council. They saw the need for a program integrating mental health and positive activities for their teens who, due to their emotional issues, often did not fit into the few available teen programs. By integrating comprehensive mental health services with a range of other teen-friendly activities, the program was built to support teens’ emotional growth in many areas including the crucial areas of emotional self-regulation and building healthy self-esteem.

Northside Center for Child Development, a 64-year-old agency in Harlem, was begun by psychologists Drs. Kenneth and Mamie Clark to provide quality mental health and educational services to children and families at a time when there were few such services for minority youth. Their program expanded greatly over the years with 522 teens receiving mental health services during this past fiscal year. The families of these Harlem and South Bronx teens self-identify as African American (58%), Latino (31%) and bi-racial (6%). Seventy-five percent of these 522 teens come from homes at or below the poverty line and 21% of our clients (ages 5 to 18) do not live with a biological parent. The teens are referred for therapy by psychiatric inpatient/ER, schools, foster care agencies and families distressed by some aspect of their teen’s behavior. Trauma is a fact of life for these teens, some of whom have witnessed, been victims of or have friends or family who have been victims of family or community violence.

Diagnostically 48% of Northside clients fell in the externalizing category (ADHD, Oppositional Defiant/Conduct Disorder, and Impulse/Disruptive Behavior Disorder) with 37% having two or more diagnoses and 93% a GAF score in the serious (44%) to moderate range (49%). Problems with self-regulation are apparent in this preponderance of externalizing diagnoses and in the analysis of initial assessment tools (ASEBA Child Behavior Checklist for ages 6 – 18 and Youth Self-Report fro ages 11-18)) while issues with both self-regulation and self-esteem were clear to their clinicians.

The outcome was the creation in 2008 of an integrated mental health program for teens. A clinician with a particular interest in teens was selected as the teen mental health social worker focusing on all aspects of teen programming including meeting regularly with teens for their input. Clinicians were provided with additional clinical training around working with teens. Existing services used by teens (tutoring; art therapy) were integrated into this program perspective. Mental health group offerings for teens were greatly expanded by adding both short-term and longer-term therapy groups: Power Source; Knowledge Empowers You (KEY); art therapy groups for sexually abused teens; Teens and Medication; Becoming a Man/Woman; Family Problem Solving; Music and Feelings. In addition, there was a clinician-led Daily Check-In group in the after-school component to help teens express problems and achievements of the day and to receive support.

The program also included activities requested by teens (cooking, Tae Bo, yoga, basketball, photography, dance) which the teens saw as fun or exciting. Group leaders saw these as venues for learning and practicing self-control, healthy self-expression, frustration tolerance, positive peer interaction and building healthy self-esteem. These activities also provided additional opportunities for the teens to develop trusting and meaningful relationships with adult leaders who also function as role models. To further self-care, positive self-identity and enlarge their vision of their potential, there were health and wellness workshops led by an RN; career roundtables and visits to worksites of interest to specific teens; and opportunities for community service (assisting in community food distribution, creating care packages for Haiti, helping to host the Northside gala). Since some teens persistently “forgot” their homework, a group was created to read and discuss a book with emotional resonance for teens living in problematic situations.

For a program working almost entirely with African American and Latino youth, positive self-identity is enhanced by programming that helps teens visualize a range of career/life opportunities greater than what many had been exposed to. They also needed opportunities to learn more about and take pride in their cultures. As part of this goal, a weekly group for teens, led by staff from the Museum of African Art focused on participatory teaching of African and Caribbean culture and history. The teens in this group created a large mural using aspects of African art with a second group using drumming as an expression of culture and self.

Teens could participate in all or in any single aspect of these additional services in addition to their ongoing therapy. By interweaving therapy groups with other therapeutic activities, the program offered teens the opportunity to develop and practice new patterns of interaction both inside and outside the therapy room.

Assessing the impact of this teen program to date is complicated by the fact that so many avenues impacting mental health, from clinician training to activity groups led by staff from a mental health perspective, occurred at the same time. The ASEBA (pre-and post-test Youth Self Report for 11- 18-year-olds) completed during this period showed the following results. When asked to respond to “I am better at handling daily life” 71% agreed, 24% felt neutral and 5% disagreed. Seventy-two percent of teens also said that they were “better able to get along with friends and other people” with 24% remaining neutral and 5% disagreeing’ (2009-2010 Quality Management Report). What seems clear to clinicians is that teens who chose to participate in the groups and other additional services displayed a greater level of self-control and self-esteem in their lives than they had at the beginning of the program. As one teen wrote recently, “I wish this program could go on forever. It is the one place that I can be myself.”

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