JOSH FEDER: The transition to college can be challenging for any adolescent, but when an adolescent has psychological conditions or they're dealing with other mental health concerns, it is especially difficult to navigate this transition. The latest edition in Summer 2024 of The Carlat Child Psychiatry Report includes an article by Drs. Alexander El Sehamy, MD, and Alan Schlechter, MD, with tips practitioners can use to help patients navigate the intimidating yet exciting transition to college. Dr. Sehamy is an attending psychiatrist at Cohen Children's Medical Center in Queens, New York, where he specializes in Pediatric Emergency Behavioral Health.

MARA GOVERMAN: And Dr. Schlechter is a clinical associate professor in the Department of Child and Adolescent Psychiatry at New York University. In addition to working as a professor, Dr. Schlechter is a child and adolescent psychiatrist at the NYU Langone's Child Study Center, where he helps college-age youth transition into adulthood.

JOSH FEDER: Welcome to The Carlat Psychiatry Podcast. This is a special episode from the child psychiatry team. I'm Dr. Josh Feder, the editor-in-chief of The Carlat Child Psychiatry Report and co-author of the Child Medication Factbook for Psychiatric Practice. 

MARA GOVERMAN: And I'm Mara Goverment, a licensed clinical social worker in Southern California with a private practice. When our patients head to college, they replace the comfort and support of parents, teachers, friends, and school activities with unprecedented workloads and stressors. Leading to an extremely high incidence of mental health disorders. Dr. El Sehamy and Dr. Schlechter write about how best to support patients during this challenging transition.

JOSH FEDER: The article, Navigating the Transition to College, describes how choosing a college that's a good fit, preparing for dorm life, learning to manage stress, and creating a support system can help patients feel better prepared to begin this new chapter of their lives. 

MARA GOVERMAN: One of the most important ways to set oneself up for success in college is by choosing a school that's a good fit. How would you advise your patients about choosing a college where they feel supported and be able to tackle the various new academic and social challenges that college can bring?

JOSH FEDER: Well, heading directly to a typical four-year college is not the right path for everyone. Some adolescents may benefit from staying home for a while after high school to receive ongoing intensive treatment. While others may do better attending community college or receiving vocational training. Or working or pursuing a gap year program. 

MARA GOVERMAN: That's a great point. There are so many different options after high school that it can be difficultto know what's the right choice. And often, parents and children may have differing ideas of what to do after high school or which college to attend. In your experience, what is the best way to advise your patients and families regarding this decision? 

JOSH FEDER: Start at the beginning. The first step is to assess your patient's current mental health status and determine if beginning college is feasible or if it may be better to delay the start of college until their mental health is in a better place.

MARA GOVERMAN: That's something I see all the time working with adolescents in a private practice. Often, my patients benefit from an extra year before starting college to mature, become more independent, gain new experiences, or get treatment for any psychological disorders that are negatively impacting their daily lives.

JOSH FEDER: That's kind of like how we often tell parents to keep their kids back at the beginning, like in kindergarten, to give them an extra year to develop. And that's why conducting a comprehensive assessment is essential; because it gives the family the perspective that they'll need to take that extra year if they need it. For many students and families, it's not something they would otherwise consider. It's also important to talk with your patient about their future goals and their own individual strengths. Some adolescents might feel pressured into attending a traditional four-year college—all their friends are doing it—but attending community college, vocational training, or working are great options as well. You have to believe that. If you don't understand that and believe it, they're not going to understand it and believeit. Asking a patient about their strengths and passions helps guide them in choosing their next step. It's an important and practical step. We know students who pursue areas of interest are more likely to succeed than those who feel pressured into choosing a specific field of study or career. How many people did you know in school who were taking their course of study because it was something their parents wanted and not something that they wanted? And it is hard for them when that happens. Additionally, those who aren't learning or working in a field they're passionate about, burn out more quickly, and nobody wants to push a student who's not going to perform well in school as those who have a passion for what they're learning. That's right. So the contrast is when you meet somebody who knows what they want, maybe they've experimented a little bit with some classes. And they light onto something that is important to them. They just kind of run with it. It's so great to watch. Now, not every student is like that. Some are going, and they're happy, and it's fine. That's great. But for the ones who have a lot of passion, it's just a gift to get to work with them. 

MARA GOVERMAN: If you're interested, you tend to be more successful in doing your work and completing your work, and it's a self-fulfilling prophecy of feeling good about yourself, and it adds to a student's well-being. 

JOSH FEDER: Absolutely. 

MARA GOVERMAN: That's why I often encourage my clients to explore all of their options after high school until they find something they love. And these discussions and explorations should start early. It's important to reassure your patients that they don't need to have discovered their passion yet and that young adulthood is a time to explore many different career paths.

JOSH FEDER: Right. Many students go into college undecided or switch their major within their first year. And those who decide to do vocational training or get a job directly after high school have the flexibility to change their path as well.I'm not going to say that it's always easy to pivot and go to undergrad if you haven't done it for a few years. However, in some countries, you might serve in the community or the military first, and those people who do that when they come back to college are often much more mature, committed, and successful in their undergrad years. 

MARA GOVERMAN: We often talk about how development And growth is uneven. And sometimes academics come into play. Sometimes, professional goals come into play, and sometimes, social-emotional goals and responsibility come into play, and we have to assess all of those and what's important and needed for each of our clients. While college isn't the only option, those who do want to leave home for college will benefit from learning what to look for when choosing a school and how to find a good fit. Big universities can offer lots of educational opportunities, but they can also feel anonymous and offer less supervision. 

JOSH FEDER: And while smaller rural schools may provide a calmer, more cohesive community, they often have fewer resources for mental health and learning support. Since colleges vary in the type of support they might provide, it's important to choose a school that will provide them with the support they need to succeed academically, socially, and emotionally. 

MARA GOVERMAN: Whether patients are moving away from home for the first time or commuting to school each day, it's important to prepare them for some of the potential challenges college can bring.

JOSH FEDER: So it's important that students develop good habits to set themselves up for success. Discuss with your patients how good sleeping and eating habits can improve mental health. 

MARA GOVERMAN: Making sure your patients know how to do laundry, maintain their hygiene, Prepare simple meals, and do basic cleaning before they go off to school.

JOSH FEDER: These simple things are so important because, for patients with a history of depression or other mental illness that impact daily functioning, it's essential to talk with them about what to do to maintain habits. Otherwise, they get overwhelmed, like their laundry's piled up, they can't find clean clothes, or they start wearing the same clothes over and over. Or they're just not taking good care of their teeth, and their breath smells. I mean, all these things can fall apart if you're not showing some intent with your patients about taking care of themselves. And remember, for a lot of people with difficulties, their parents have been kind of reminding them and having them do that stuff. This is why it's importantto start talking about this much earlier, I mean in childhood, and then of course through high school, with the idea that the goal at the end is that people are pretty much able to take care of themselves and are doing so at home before they leave. 

MARA GOVERMAN: Give these kids a good idea of what to expect and what to do if things don't go how they planned. Help your patients learn to recognize the warning signs of a relapse. This may help them prevent a depressive episode. Or get help soon after their symptoms begin. 

JOSH FEDER: And look, all of this is before we even get to the medications. Let's talk about medication management when patients are living away from home for the first time. It's a good idea to practice beforehand. You can ask your patient to begin taking medications without prompting at home so that they are more likely to continue them as a habit when they're at school. It's helpful to set a daily reminder or keeping medications in a place where they're likely to remember them, like with your toothbrush and toothpaste is a typical one, and then, they'll be more likely to take their medicine every day and stay consistent in that habit.

MARA GOVERMAN: It's also important to have the conversation to educate patients about sharing their stimulants with their friends at college. 

JOSH FEDER: I don't know if we talk about that later, but you're right. That's a really bad idea. You run out of your medication—you're committing a felony, by the way—and it makes people more likely to go in and steal your pills. And, of course, it's not good for the person receiving them if they've got a medical problem for which they shouldn't be on stimulants. All kinds of good reasons not to. 

MARA GOVERMAN: You have to build these habits early because there will be all sorts of new distractions when they're at school. Kids can start practicing picking up their own medications from the pharmacy so that they are prepared to refill their prescriptions while at school. In addition to developing these self-care habits, how else can we help our patients set themselves up for success in college? 

JOSH FEDER: Talk to your patient about the importance of developing good study habits and time management skills. That'll help them succeed in their classes. Here's some other helpful tips you can share with your patients. Reach out for help early if you feel like you're falling behind. Professors have office hours every week, and many classes have tutors or teaching assistants who also are available to help you. Stay organized. That's hard to do. But, students, if they write down all of their due dates in a planner, then they won't lose points by forgetting to do an assignment. And read the syllabus thoroughly. Professors will weigh homework, tests, papers, and class participation differently, and you need to take note of that and other expectations and requirements that are in the syllabus. And sometimes, you drop something cause you don't have time for it, but maybe it's something that doesn't cost a lot of points. If you gotta do it, you gotta do it. Try different study methods until you figure out what works best for you. Maybe it's being in the library—or I guess they call those media centers now—but by yourself so that people aren't bugging you. Maybe it's on your bed in the dorm room with music going, but usually not, and almost never it includes a beer or weed. We don't like that. That usually doesn't help people be motivated or get their work done. And, of course, keep in mind that different classes often require different study strategies. Take advantage of campus resources. They've got writing centers, tutoring for math, and everything else. Academics support places where they can maybe get you extra time on a test or quiet places to take a test if you've got documentation of ADHD or something like that. If you're a student who's received academic accommodations in high school, you need to inquire about receiving accommodations in college as well.

MARA GOVERMAN: I totally agree. Executive function skills, including staying organized with assignments and knowing how to reach out for support, are important skills that every adolescent should be practicing and learning. Students may feel very overwhelmed and stressed from time to time and may put a lot of pressure on themselves to do well. How do you think students should best cope with this area of stress? 

JOSH FEDER: Well, I think you hit it on the head with knowing to reach out. If there is only one skill that I want all my patients—all my families to know—it's asking for help. I mean, that's like the most important thing, and Dr. El Sehamy and Dr. Schlechter write in their article that the biggest predictor that a student's going to pass their first year of college—you know what it is? It's whether they feel they belong. So you can't just be studying all the time.

MARA GOVERMAN: That's a great point. College has so much to offer in addition to academics, and by getting involved with other activities on campus, finding their people, students are able to de-stress and cope in healthy ways.

JOSH FEDER: So, I ask patients to make a list of clubs or sports or activities they're interested in and explain to them how joining these groups is one of the best ways to find those people, find your tribe with common interests, and make new friends. I recommend doing something similar with your own patients, even if it's just an informal brainstorm about ways that they can get involved on campus. So earlier, we were talking about when you have your medications at school and keeping them, like with your toothbrush, so you don't forget them—stuff like that. But it's something to remember that stimulant medications have quite a street value. And it's one thing to put your pill next to your toothbrush for the morning, maybe one pill, but you don't want to put your whole bottle there. You need to have a lock box—that has like a cable that's wrapped around your bed frame just to make it harder. It is never going to be impossible for people to steal your stuff, but—and you don't want to make a big deal of it—I mean, you have to be on the down low about the fact that you've got these very precious stimulant medications, really any medication, but stimulants are the big thing, a lot of sticky fingers, I mean—people are coming in and out of dorm rooms and stuff. So don't tell people about it, keep that there. When you go and take a shower, you're going to put your wallet in there anyway—and other stuff that are valuables—and you keep your supply in there too. 

MARA GOVERMAN: And what do you tell parents to buy it? What do you purchase?

JOSH FEDER: Oh, Staples has these. Or other kinds of office-type stores, and you can probably even get it at pretty much any general store-type place.

MARA GOVERMAN: And you ask for a lockbox? Is that it?

JOSH FEDER: Yeah, it's just like a cash box. You might need to take the dividers out of it. But it's got a hole in the back, and they sell these lockable cables for them, and then you get it secured to your bed frame. And that way, you're just less likely to be the person who's calling up your doctor, maybe two weeks into your medication, saying Oh, my medicine was stolen. Well, that happens, and maybe once you can get away with having the pharmacy fill it again—but twice? That's not going to happen. If it happens twice during the school year, you may be out of luck. And then you don't have your medicine, and then you're having difficulty focusing and studying.

MARA GOVERMAN: We've talked a lot about how to support our patients. But what advice would you give to parents to help their children? 

JOSH FEDER: Colleges don't accept you if they don't think you're going to pass the classes, right? So, the thing is to support your child in their activities and friendships, in addition to the academics. If the child is struggling academically, encourage parents to refrain from expressing anger. Instead, talk with them about problem-solving, what they can do to learn from the experience and do better next time, and get additional help. And encourage parents to remind kids about those resources that are available for them on campus, such as tutoring, writing centers, and professors' office hours.

MARA GOVERMAN: Talk with parents about when a quick visit might be helpful—or not. At least for the first few weeks, staying on campus can help students make new friends, feel comfortable with the new routine, and get used to living away from home. 

JOSH FEDER: Just thinking about living away from home can be stressful for emerging college students, especially the aspect of living with roommates. The article, Navigating the Transition to College, provides questions you might want to ask your patient regarding living with roommates. Questions like Have you ever shared a room? What was that? Like what ideas do you have for avoiding problems with roommates? There's a great book out there called The Naked Roommate that talks about what it's like when you first go away to college and have to share a room.

MARA GOVERMAN: Encourage your patient to establish some ground rules with their roommates during the first week of school. Some helpful topics to discuss with the roommates may be sleeping habits, inviting friends over, keeping the room clean, and how they prefer to handle conflicts.

JOSH FEDER: That's the most important one. I mean, these things seem obvious, but a lot of times people just don't have those conversations, and then they're all angry, and they don't communicate, and then conflicts are bound to arise.Conflicts always arise from time to time, so it's important to talk with your patient about how they plan to address these issues, whether it be with roommates, friends, romantic partners. Some other questions from the article that can prompt discussions are: What ideas do you have to manage the ups and downs of new friendships? Or how do you plan to respond to people with different political, religious, and cultural beliefs? And do you plan to date? What ideas do you have to stay safe physically and emotionally? Really important to talk about consent, right?

MARA GOVERMAN: Speaking of staying safe, it is important to have a discussion with your patients about substance use and prepare them for how they plan to navigate this aspect of college. One way to introduce this conversation is by stating that other students may drink, smoke, or use other substances. Then ask your patient if they plan to use substances at college, and if so, how much, and how do they plan to manage it? 

JOSH FEDER: Talk with your patient about how they plan to answer people when they're offered a substance they don't want to use and address any questions or concerns they may have about the topic. It's a good thing to role-play—Like, I don't want that. Oh, take it. I don't want it. I gotta study—whatever it is, but being a broken record is probably one of the better techniques—I don't want it. No, thank you. I don't want it.—It takes about seven times that most people give up. 

MARA GOVERMAN: Yeah, coming up with a few phrases that when they're activated helps a lot of our patients. While it's essential to help your patients prepare for college, it's also important that patients have the support they need once they arrive at school. What do practitioners need to know when deciding if they should continue to treat their patient after they leave for college? 

JOSH FEDER: The first question you need to ask yourself is: Can I treat the patient legally? Some states prohibit treating students in another state and if you're not able to provide care in other states, you need to check online to see if you're eligible for an expedited licensing process. 

MARA GOVERMAN: Another question you may want to ask yourself is, Is the patient stable? Consider how often your patient needs to see you; and if you are able to see them as often as they need treatment. And would a virtual session be helpful for them? Would meeting virtually provide your patient with the support they need, or would connecting them with a provider at school be more helpful? 

JOSH FEDER: You have got to consider the question: Will the patient allow me to work with the school and parents?And you can expand your reach by obtaining authorization from your patient to talk with parents in the university. That includes health centers, learning and disability centers, registrars, and housing offices. While you can generally disclose protected health information to parents or other school officials in an emergency, you'll want to ask your patient to find local care if they decline to sign releases.

MARA GOVERMAN: Lastly, you may wish to know: Will the school work with me? You should ask the health center and the registrar how the university interprets the Family Educational Rights and Privacy Act (FERPA) and HIPAA laws. And you may also wish to reach out ahead of time to student disability services, health services, and housing to create a team to support your patients.

JOSH FEDER: You've got to start talking with your patients early about what happens after high school; and help your patient develop skills to move on to the next phase of their life. We hope this podcast provided you with some helpful tips to navigate these conversations with your patients! For more information about the topic, check out the article, Navigating the Transition to College, by Dr. El Sehamy and Dr. Schlechter, available on our website. The Newsletter Clinical Update is available for subscribers to read in The Carlat Child Psychiatry Report. Hopefully, people will check it out. Subscribers get printed issues in the mail and email notifications when new issues are available on the website. Subscriptions also come with full access to all the articles on the website and CME credits.

MARA GOVERMAN: And everything from Carlat Publishing is independently researched and produced. There's no funding from this pharmaceutical industry. 

JOSH FEDER: Yes, the newsletters and books we produce depend entirely on reader support. There are no ads, and our authors don't receive industry funding. That helps us to bring you unbiased information that you can trust.

MARA GOVERMAN: And as always, thanks for listening, and have a great day!