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Health Services: The Transition from Child to Adult

How to improve the transition. By Deborah Cohen, Ph.D.

The 21st Century Cures Act has been both lauded and criticized, but one thing about it is for sure – the bill was a landmark achievement for receiving bipartisan support in an era when bipartisanship is scarce. It will go a long way in improving coordination of federal mental health initiatives. But there is still more work to be done at the state level, particularly in Texas, to ensure older adolescents and young adults who are served by the mental health system can successfully transition into productive adults.

Stoppage of care is especially prevalent for older adolescents and young adults ages 16-25. This break in treatment is not only unfortunate but also untimely. Major illnesses such as schizophrenia and bipolar disorder first emerge during this age range, and treatment for these illnesses needs to happen early.

The primary barrier to treatment for this age group is bureaucratic. Like Texas, many states restrict the entrance of individuals over the age of 17 into the adult mental health system. In fact, less than 30 percent of youths served within Texas’ public mental health system at age 17 transition into adult services. This is a problem. Texas can do better.

Youths transitioning from the children’s mental health system either experience an abrupt end or, at best, inadequate services intended for middle-aged adults. Dysfunction during this time leads to compromised vocational development and increased involvement with the criminal justice system.

Negative outcomes are particularly compounded for former foster youths, who are more likely to have greater mental health severity, a substance use disorder, housing instability and criminal justice involvement than youths with no experience in the foster care system. This can lead to difficulty in finding a job and reduces the likelihood of these young adults becoming economically independent.

Texas has made recent progress, however. A new pilot program targeting youths and young adults recently diagnosed with schizophrenia is in 10 mental health centers using federal funds set aside specifically for early serious mental illness.

This is a good start, but unfortunately there is no developmentally appropriate assistance for young adults who are heavily involved in child mental health services, and for those diagnosed with a new serious mental illness that is not schizophrenia.

The passage of the Cures Act created an unfettered opportunity to improve our mental health service delivery without necessarily having to spend more money. This can be done by including 18- to 25-year-old individuals who were served as children under the 1915c waiver as a population who can be served under the 1915i waiver. Both of these federal waivers focus on reducing hospitalization and incarceration, and allow for creative solutions to keep individuals in the community.

Another way to create change is to blend funds specified for transition services under juvenile justice, child welfare and special education to provide transition-specific services at one agency in a community instead of segmenting it across multiple agencies. Lawmakers should also use part of the pre-existing federal funds set aside for early serious mental illness to create a program for young adults with a serious mental illness that is not schizophrenia.

It’s specifically important to realign the funding to ensure that services focus on balancing one’s mental illness toward leading a successful adult life. The state should provide support to the community mental health centers to develop new programming that creates a better bridge between child and adult mental health services.

This focus would allow for greater progress and reduced long-term dependence on the public systems. Chronic unemployment has a high societal cost, making transition programming and policies a compelling public policy interest.

As Texas House Speaker Joe Straus said, “A smarter approach to mental health will improve treatment and care while saving taxpayers money."

If we intervene earlier, it will lead to savings down the road. The 21st Century Cures Act is the first step for system transformation, but we have a long way to go. Texas should lead the way.

Deborah Cohen, Ph.D., is a research associate in the School of Social Work at The University of Texas at Austin. Email:

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