Transition of care from child to adult mental health services: the great divide

The transition of young adults with lifelong urological needs from pediatric to adult services: An international children's continence society position statement

INTRODUCTION

Children with urinary tract disorders managed by teams, or individual pediatricians, urologists, nephrologists, gastroenterologists, neurologists, psychologists, and nurses at some point move from child-centered to adult-centered health systems. The actual physical change is referred to as the transfer whilst the process preceding this move constitutes transition of care. Our aims are twofold: to identify management and health-service problems related to children with congenital or acquired urological conditions who advance into adulthood and the clinical implications this has for long-term health and specialist care; and, to understand the issues facing both pediatric and adult-care clinicians and to develop a systems-approach model that meets the needs of young adults, their families and the clinicians working within adult services.

METHODS

Information was gleaned from presentations at an International Children's Continence Society meeting with collaboration from the International Continence Society, that discussed problems of transfer and transitioning such children. Several specialists attending this conference finalized this document identifying issues and highlighting ways to ease this transition and transfer of care for both patients and practitioners.

RESULTS

The consensus was, urological patients with congenital or other lifelong care needs, are now entering adulthood in larger numbers than previously, necessitating new planning processes for tailored transfer of management. Adult teams must become familiar with new clinical problems in multiple organ systems and anticipate issues provoked by adolescence and physical growth. During this period of transitional care the clinician or team assists young patients to build attitudes, skills and understanding of processes needed to maximize function of their urinary tract-thus taking responsibility for their own healthcare needs. Preparation must also address, negotiating adult health care systems, psychosocial, educational or vocational issues, and mental wellbeing.

CONCLUSIONS

Transitioning and transfer of children with major congenital anomalies to clinicians potentially unfamiliar with their conditions requires improved education both for receiving doctors and children's families. Early initiation of the transition process should allow the transference to take place at appropriate times based on the child's development, and environmental and financial factors. Neurourol. Urodynam. 36:811-819, 2017. © 2016 Wiley Periodicals, Inc.

Health Care Use During Transfer to Adult Care Among Youth With Chronic Conditions

OBJECTIVE

To compare health care use and costs for youth with chronic health conditions before and after transfer from pediatric to adult health care services.

METHODS

Youth born in Ontario, Canada, between April 1, 1989, and April 1, 1993, were assigned to 11 mutually exclusive, hierarchically arranged clinical groupings, including "complex" chronic conditions (CCCs), non-complex chronic conditions (N-CCCs), and chronic mental health conditions (CMHCs). Outcomes were compared between 2-year periods before and after transfer of pediatric services, the subjects' 18th birthday.

RESULTS

Among 104,497 youth, mortality was highest in those with CCCs, but did not increase after transfer (1.3% vs 1.5%, P = .55). Costs were highest among youth with CCCs and decreased after transfer (before and after median [interquartile range]: $4626 [1253-21,435] vs $3733 [950-16,841], P < .001);Costs increased slightly for N-CCCs ($569 [263-1246] vs $589 [262-1333], P < .001), and decreased for CMHCs ($1774 [659-5977] vs $1545 [529-5128], P < .001). Emergency department visits increased only among youth with N-CCCs (P < .001). High-acuity emergency department visits increased CCCs (P = .04) and N-CCCs (P < .001), but not for CMHC (P = .59), who had the highest visit rate. Among the 11 individual conditions, costs only increased in youth with asthma (P < .001), and decreased (P < .05) in those with neurologic impairment, lupus, inflammatory bowel disease, and mood/affective disorders.

CONCLUSIONS

Pediatric transfer to adult care is characterized by relatively stable short-term patterns of health service use and costs among youth with chronic conditions.

Transitional care and paediatric surgery

Merits urgent attention

Being a Parent to a Young Adult with Mental Illness in Transition to Adulthood

Parents of young adults with mental illness may face a continued demand for support, even though their children have reached the age of majority. The aim of this study was to explore relatives' experiences of parenting a young adult with mental illness in transition to adulthood. Individual interviews were conducted and analysed according to Grounded Theory. The results showed that relatives experienced powerlessness and a sense of inescapable duty with limited possibilities to be relieved. With a family nursing approach, relatives can be supported and, when the young adults' needs of care are met, they can be relieved from their burden of responsibility.

Young people who self-harm: a prospective 1-year follow-up study

PURPOSE

To explore repetition, service provision and service engagement following presentation of young people to emergency services with self-harm.

METHODS

969 patients who presented to accident and emergency services after self-harm were followed up prospectively for a period of 1 year. Data on rates, method, clinical history, initial service provision, engagement and repetition (defined as re-presenting to emergency services with further self-harm) were gathered from comprehensive electronic records.

RESULTS

Young people were less likely to repeat self-harm compared to those aged 25 and above. A psychiatric history and a history of childhood trauma were significant predictors of repetition. Young people were more likely to receive self-help as their initial service provision, and less likely to receive acute psychiatric care or a hospital admission. There were no differences in engagement with services between young people and those aged 25 and above.

CONCLUSION

Younger individuals may be less vulnerable to repetition, and are less likely to represent to services with repeated self-harm. All young people who present with self-harm should be screened for mental illness and asked about childhood trauma. Whilst young people are less likely to be referred to psychiatric services, they do attend when referred. This may indicate missed opportunity for intervention.

Mental disorders and transition to adult mental health services: A scoping review

Background

Data are progressively accumulating regarding the transition to adult services.

Methods

A comprehensive search using the MEDLINE, Embase, PsycINFO, and Cochrane databases up until 16 March 2015 was conducted in order to summarize recent evidence on the transition from child to adult mental health services for patients with mental disorders. Authors extracted data and assessed study quality independently.

Results

The main findings of the 33 included studies were discussed taking into consideration four aspects: experiences of patients, carers, and clinicians, accounts of transition, current services models and protocols, and outcomes of transition. Of the 33 studies, 17 focused on a specific mental disorder: seven on attention deficit hyperactivity disorder, four on intellectual disability, three on eating disorders, two on serious emotional disorders and one on autism spectrum disorder. An attempt was also made to integrate the studies’ conclusions in order to improve transitional care.

Conclusions

The review reveals an evident need for longitudinal, controlled, health services research to identify and evaluate optimal service models with systematic and seamless transition protocols for patients with mental disorders requiring continuity of care into adult mental services.

Program manager perspectives on the service system to meet the needs of youth with concurrent disorders: findings from a Canadian national survey

Background

Concurrent mental health and substance use issues are a serious problem for adolescents and transition-aged youth. Service providers across sectors must be involved in informing system change to meet youth needs. This study examines stakeholder perspectives on services for youth with concurrent disorders including 1) clinical issues in youth services; 2) priority system issues; and 3) optimal knowledge translation strategies to enhance researcher-stakeholder communication.

Methods

A database of youth clinical services across Canada was developed. Program managers (n = 481) at cross-sectoral (mental health, addictions, justice, child welfare, advocacy, and outreach) youth-serving (aged 12–24) programs were invited to complete an online survey; 232 responded. Survey questions concerned youth needs, program characteristics, priorities for service system enhancement; and usual and preferred knowledge translation methods.

Results

Across service sectors, the mean estimated proportion of youth using services with concurrent mental health and substance use problems was 55 %. Program managers reported routine screening for mental health and substance use concerns (66 %), referring to other agencies to meet the concurrent disorder needs of youth (54 %), offering specific programming for concurrent disorders (42 %), and program evaluation (48 %). Notably, mental health programs were significantly less likely to offer concurrent disorders services than addictions programs. Where services do exist, most are targeted at youth aged 12–18 years, with fewer services available for transition-aged youth. Endorsement of various system change goals exceeded 80 %, with a particular emphasis on improving access to services (49 %), ensuring a continuum of services for varying levels of severity (37 %), and improved integration across sectors (36 %). Preferred knowledge exchange methods were workshops and websites for receiving information; and focus groups or surveys, rather than intensive participation on research teams, to inform research.

Conclusions

There is a high need to build capacity across most sectors for meeting the needs of youth with co-occurring mental health and substance use problems, especially for transition-aged youth. In addition, limits in program evaluation should be addressed. Innovative knowledge exchange strategies are needed to better meet the needs of youth with concurrent disorders. Although service providers expressed readiness to participate in service enhancement and knowledge translation activities, effective, feasible approaches must integrate strategies likely to result in desired clinical outcomes, given clinical workload challenges.

Transition Planning for the College Bound Adolescent with a Mental Health Disorder

Health promotion, disease prevention and anticipatory guidance are the hallmarks of nursing practice, particularly in pediatrics. While there is a wealth of information on anticipatory guidance for the pediatric patient at different ages and developmental stages, there is a paucity of information on anticipatory guidance for the adolescent and emerging adult in transitioning to manage their own health care. While an established need for anticipatory guidance and a transition plan from pediatric to adult health care is apparent for youth routinely followed for significant medical, intellectual, or developmental conditions, a group particularly vulnerable to destabilization of their health as they transition to self-directed adult health care management is composed of youth with mental health disorders. The risk for destabilization increases as they move away from social supports to the university setting. This article reviews available literature on anticipatory guidance for the college bound adolescent with a mental health disorder and makes recommendations for transition planning including examining the college and community services that would support mental health as well as personal choices regarding lifestyle habits while attending the university. Recommendations are made for nurses to be the leaders in filling this anticipatory guidance gap in preparing youth with mental health disorders for a successful transition to and through college life.

The pathways to mental healthcare worldwide: a systematic review

PURPOSE OF REVIEW

Pathways-to-care studies represent a valid and cost-effective tool to provide information on patients' access to psychiatric care. However, no direct comparison of data concerning the pathways to mental healthcare, at the world level, is available yet.

RECENT FINDINGS

Data obtained from different countries of the world may offer a global perspective on psychiatric pathways to mental healthcare, highlighting the strengths and weaknesses of different mental health systems and reflecting cultural, economic, social and political differences. We evaluated all studies that used a standardized methodology to describe pathways to mental healthcare of all adult patients, presenting for the first time to psychiatric services.

SUMMARY

Our findings highlight that considerable variations of pathways to mental healthcare across different countries still exist. A consensus on the quality standards of psychiatric care should be reached and actions to ensure their implementation in low-middle income countries should be taken in the near future. The role of primary care doctors and social networks still represent an unsolved issue for psychiatric care worldwide. Stigma and discrimination towards patients with mental illnesses may still represent a relevant limiting factor for equal delivery of mental healthcare.

Transition to adult services for young people with mental health needs: A systematic review

BACKGROUND

Young people's transition from child and adolescent (CAMHS) to adult mental health services (AMHS).

OBJECTIVES

To systematically review evidence on the effectiveness of different models of CAMHS-AMHS transitional care, service user and staff perspectives, and facilitators of/barriers to effective CAMHS-AMHS transition.

DATA SOURCES

A systematic search in May 2012 of Medline, PsycINFO, CINAHL, EMBASE, AMED, Health Business Elite, HMIC, Cochrane Database, Web of Science and ASSIA; ancestral searches; and consultation with experts in the field.

STUDY SELECTION

Qualitative, quantitative and mixed-methods primary research on the CAMHS-AMHS health-care transition of young people (aged 16-21 years) with mental health problems.

DATA EXTRACTION

Two reviewers independently completed a standardised data extraction form and critically evaluated identified documents using a validated appraisal tool for empirical studies with varied methodologies.

RESULTS

A total of 19 studies of variable quality were identified. None were randomised or case-controlled trials. Studies incorporating service user/carer perspectives highlighted the need to tackle stigma and provide accessible, age-appropriate services. Parents/carers wanted more involvement with AMHS. Transitional care provision was considered patchy and often not prioritised within mental health services. There was no clear evidence of superior effectiveness of any particular model.

CONCLUSIONS

High-quality evidence of transitional care models is lacking. Data broadly support the development of programmes that address the broader transitional care needs of 'emerging adults' and their mental health needs but further evaluation is necessary. Developing robust transitional mental health care will require the policy-practice gap to be addressed and development of accessible, acceptable, responsive, age-appropriate provision.

Assessing readiness for transition from paediatric to adult health care: Revision and psychometric evaluation of the Am I ON TRAC for Adult Care questionnaire

AIM

To refine and psychometrically test the Am I ON TRAC for Adult Care questionnaire.

BACKGROUND

Inadequate transition to adult care for adolescents with special healthcare needs has been associated with greater risk of treatment non-adherence, lack of medical follow-up, increased morbidity and mortality. Presently, there are no well-validated measures assessing adolescents' readiness to transition from paediatric to adult medical care.

DESIGN

Descriptive cross-sectional study.

METHODS

The Am I ON TRAC for Adult Care questionnaire was refined to improve the instrument's methodological soundness. A literature review informed the revisions. A convenience sample of 200 adolescents, 12-19 years, was recruited from four outpatient clinics at a paediatric hospital in Western Canada between April-June 2012. Construct validity was evaluated by Exploratory Factory Analysis; concurrent validity was assessed using the Psychosocial Maturity Index. Internal consistency was evaluated by computing Cronbach's alpha estimates.

RESULTS

Factor analysis of the knowledge items identified a 14-item unidimensional scale. Knowledge and behaviour sub-scale scores increased with age, with a stronger relationship between knowledge and age. Psychosocial maturity correlated with both sub-scale scores, but had a stronger association with behaviour. Psychosocial maturity and age had a weak but significant correlation suggesting age is a loose proxy for maturity. Only 27% of 17-year olds, but 62% 18-year olds, scored above the behaviour cut-off for transition readiness.

CONCLUSION

The revised Am I ON TRAC for Adult Care questionnaire is a psychometrically sound measure that has potential to be used as a readiness assessment tool in both clinical practice and research.

Swedish Young Adults' Experiences of Psychiatric Care during Transition to Adulthood

The number of young adults with mental illness and the need of psychiatric care has increased during the last decades. The aim of the study was to explore young adults' experiences of psychiatric care during transition to adulthood. Individual interviews were conducted with 11 young adults and analysed according to Grounded Theory. The analyses results showed that support was a prerequisite for transition to adulthood and striving to reach recovery. By being encountered as a person and with a supportive environment, young adults can be motivated to continue care and be encouraged to express feelings.

Professional care after deliberate self-harm: a qualitative study of young people's experiences

BACKGROUND

Deliberate self-harm (DSH) is increasingly common among young people. At the same time, treatment and support after DSH are often hampered by low compliance.

AIM

To explore young people's perceptions of care and support during a 6-month period following their first contact for DSH.

METHODS

We conducted nine semistructured interviews with young people aged 16-24 years 6 months after their first contact for DSH. The interviews were analyzed using qualitative content analysis.

RESULTS

Three main themes were extracted from the interviews. "Am I really in good hands?" describes whether the participants felt they were being listened to and taken seriously and whether they could rely on the competence of the professionals and the appropriateness of treatment, including keeping agreements and communication with other relevant agencies. "Help should match life circumstances" comprises how basic practicalities such as travel possibilities affect treatment and concomitant assistance in everyday living. Financial matters and jobseeking were perceived as necessary for optimal treatment and well-being. "Making yourself better" includes participants' efforts to manage on their own, through realizing their own responsibility to be engaged and actively take part in treatment planning.

CONCLUSION

Flexibility and responsiveness to young people's own views and specific needs in treatment arrangements are of crucial importance. The significance of basic practical help cannot be underestimated and should not be overlooked.

Youth services: meeting the mental health needs of adolescents

Objectives

Youth mental health services are poised for a paradigm shift. Recent epidemiological evidence confirms the seriousness of adolescence as a risk period for mental ill-health - 50% of all adult mental disorders begin before the age of 16% and 75% before the age of 25. Here, we identify issues with transition of care between CAMHS-AMHS service, and effectiveness of early intervention services.

Methods

We provide a selective review providing evidence of adolescence as a risk period, discuss CAMHS-AMHS service transition problems, and discuss avenues for change to implement the early intervention model across youth mental health.

Results

Traditional service structures,with paediatric -adult split at 16–18 years increasingly appear not fit for purpose. A radical redesign of youth mental health services is not only necessary, it is also feasible and achievable, as illustrated by a pilot Birmingham youth service – Youthspace.

Conclusions

Pilot youth mental projects currently underway can help radically redesign the existing child and adolescent services. This will in turn lead to an improvement in the young people's experience of engagement with the services so that they too have a positive future.

Mental health services for individuals with high functioning autism spectrum disorder

Adolescents and adults with an autism spectrum disorder (ASD) who do not have an intellectual impairment or disability (ID), described here as individuals with high-functioning autism spectrum disorder (HFASD), represent a complex and underserved psychiatric population. While there is an emerging literature on the mental health needs of children with ASD with normal intelligence, we know less about these issues in adults. Of the few studies of adolescents and adults with HFASD completed to date, findings suggest that they face a multitude of cooccurring psychiatric (e.g., anxiety, depression), psychosocial, and functional issues, all of which occur in addition to their ASD symptomatology. Despite this, traditional mental health services and supports are falling short of meeting the needs of these adults. This review highlights the service needs and the corresponding gaps in care for this population. It also provides an overview of the literature on psychiatric risk factors, identifies areas requiring further study, and makes recommendations for how existing mental health services could include adults with HFASD.

Transition from child and adolescent to adult mental health services in the Republic of Ireland: an investigation of process and operational practice

AIM

Ensuring a seamless transition from child to adult mental health services poses challenges for services worldwide. This is an important process in the ongoing care of young people with mental illness; therefore, it is incumbent on all countries to probe their individual structures to assess the quality of mental health service delivery to this vulnerable cohort. To date, there have been no published studies on the transition from Child to Adult Mental Health Services in the Republic of Ireland. To this end, a nationwide survey of transition policies of community mental health teams in both services was conducted in order to compare best practice guidelines for transition with current process and experience in clinical practice.

METHOD

Structured interviews were conducted with 57 consultant psychiatrists (representing 32 CAMHS teams and 25 AMHS teams) to obtain information on annual transition numbers, existing transition policies and operational practice from the professional perspective.

RESULTS

Numbers of young people considered suitable for transfer to adult services (M = 7.73, SD = 9.86, n = 25) were slightly higher than numbers who actually transferred (M = 4.50, SD = 3.33, n = 20). There is a lack of standardized practice nationwide regarding the service transition boundary, an absence of written transition policies and protocols, and minimal formal interaction between child and adult services.

CONCLUSIONS

The findings suggest that there are critical gaps between current operational practice and best practice guidelines. Future studies will investigate the impact this has on the transition experiences of young people, their carers and health-care professionals.

Transition of care for adolescents with disorders of sex development

Disorders of sex development (DSDs) continue to present many challenges. A clear consensus among clinicians has emerged in paediatric care; however, the same cannot be said of adult care services. Moreover, transition to adult care is a process that takes many years. Although evidence-based models of transitional care do exist in other medical specialities, few studies have been conducted in adolescents with DSDs, and a clear and pressing need exists for further research to guide the care of these patients. A general move towards independence and self-responsibility is common to all transition programmes, but specific issues for those with a DSD include disclosure, genital examinations and potential vaginal treatments. Psychological support underpins the whole transition process for patients with a DSD and encourages an individual approach to develop. In this Perspectives article, we describe the barriers to successful transition in this setting and outline suggestions to overcome them.

Annual research review: Child and adolescent mental health interventions: a review of progress in economic studies across different disorders

BACKGROUND

Resources for supporting children and adolescents with psychiatric disorders continue to be scarce. Economics research can identify current patterns of expenditure, and help inform allocation of treatment and support resources between competing needs or uses.

SCOPE AND METHODS

The aim was to identify the costs of supporting children and adolescents, the economic impacts of childhood psychiatric disorders in adulthood and any new evidence on the cost-effectiveness of interventions. An electronic search of databases (including PubMed, Medline and Psychinfo) identified peer-reviewed journal articles published between 2005 and 2012.

FINDINGS

Sixty-seven papers provided data on support and treatment costs now or in the future, or cost-effectiveness analyses of services. Half the articles came from the United States. Most articles focussed on autism spectrum disorder (ASD; 23 articles), attention deficit hyperactivity disorder (ADHD; n = 15), conduct disorder (CD; n = 7), and anxiety or depression (n = 8).

CONCLUSION

Only 14 studies used a cost perspective wider than health care; most included education costs (n = 11), but only five included costs to the justice system. The number of studies estimating costs to the family has increased, particularly for children with autism spectrum disorder (ASD). In the United Kingdom, support costs for children and adolescents with conduct disorder (CD) appear to be lower than for those with attention deficit hyperactivity disorder (ADHD), although for the United States, the opposite may be true. Support costs for children and adolescents with ASD may be higher than both CD and ADHD. However, there were many differences between the samples and the methods employed making comparisons between studies difficult. Outcomes in adulthood include negative impacts on (mental) health, quality of life, public sector services, employment status and income. The evidence base is improving for child and adolescent psychiatric disorders, although only one full cost-effectiveness analysis was identified since the previous review published in 2012. However, we still do not know enough about the economic implications of support and treatment for specific disorders.

The effect of organisational resources and eligibility issues on transition from child and adolescent to adult mental health services

OBJECTIVES

To investigate the organisational factors that impede or facilitate transition of young people from child and adolescent (CAMHS) to adult mental health services (AMHS).

METHODS

Thirty-four semi-structured interviews were conducted with health and social care professionals working in child and adult services in four English NHS Mental Health Trusts and voluntary organisations. Data were analysed thematically using a structured framework.

RESULTS

Findings revealed a lack of clarity on service availability and the operation of different eligibility criteria between child and adult mental health services, with variable service provision for young people with attention deficit hyperactivity disorder, autism spectrum disorders and learning disabilities. High workloads and staff shortages were perceived to influence service thresholds and eligibility criteria.

CONCLUSIONS

A mutual lack of understanding of services and structures together with restrictive eligibility criteria exacerbated by perceived lack of resources can impact negatively on the transition between CAMHS and AMHS, disrupting continuity of care for young people.

Evaluating a brief, internet-based intervention for co-occurring depression and problematic alcohol use in young people: protocol for a randomized controlled trial

BACKGROUND

Depression and alcohol misuse represent two of the major causes of disease burden in young adults. These conditions frequently co-occur and this co-occurrence is associated with increased risks and poorer outcomes than either disorder in isolation. Integrated treatments have been shown to be effective, however, there remains a significant gap between those in need of treatment and those receiving it, particularly in young people. The increased availability of Internet-based programs to complement health care presents a unique opportunity in the treatment of these conditions.

OBJECTIVE

The objective of our study was to evaluate whether a brief, Internet-based, self-help intervention (the DEAL [DEpression-ALcohol] Project) can be effective in treating co-occurring depression and problematic alcohol use in young people (18-25 years old).

METHODS

The evaluation will take the form of a randomized controlled trial (RCT), comparing the DEAL Project with an attention-control condition (HealthWatch). The RCT will consist of a four-week intervention phase and a 24-week follow-up. It will be entirely Internet-based and open Australia-wide to young people 18 to 25 years old. The primary outcomes will be change in depression symptoms and alcohol use at 5, 12, and 24 weeks post baseline. Secondary outcomes include change in general functioning and quality of life, anxiety/stress symptomatology, and a number of other depression/alcohol related outcomes. Process analysis will also measure engagement across the conditions.

RESULTS

This study is currently ongoing with preliminary results expected in late 2014.

CONCLUSIONS

This study, to our knowledge, will be the first RCT of a Internet-based treatment for comorbid depression and problematic alcohol use in any age group. If successful, the program represents a novel and innovative approach to addressing the significant harms associated with these conditions and will be an invaluable resource to those not receiving help elsewhere.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry; ACTRN12613000033741; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=363461 (Archived by WebCite at http://www.webcitation.org/6Mrg9VFX4).

Managing transition with support: experiences of transition from child and adolescent psychiatry to general adult psychiatry narrated by young adults and relatives

Young adults with mental illness who need continuing care when they turn 18 are referred from child and adolescent psychiatry to general adult psychiatry. During this process, young adults are undergoing multiple transitions as they come of age while they transfer to another unit in healthcare. The aim of this study was to explore expectations and experiences of transition from child and adolescent psychiatry to general adult psychiatry as narrated by young adults and relatives. Individual interviews were conducted with three young adults and six relatives and analysed according to grounded theory. The analysis resulted in a core category: managing transition with support, and three categories: being of age but not mature, walking out of security and into uncertainty, and feeling omitted and handling concerns. The young adults' and relatives' main concerns were that they might be left out and feel uncertainty about the new situation during the transition process. To facilitate the transition process, individual care planning is needed. It is essential that young adults and relatives are participating in the process to be prepared for the changes and achieve a successful transition. Knowledge about the simultaneous processes seems to be an important issue for facilitating transition.

Twenty years of research shows UK child development team provision still varies widely for children with disability

OBJECTIVES

To identify how services provided by child development teams (CDTs) have changed over 20 years. To what extent have major government initiatives aiming to improve the lives of children with disability and their families been implemented by teams?

DESIGN

Survey sent to every UK CDT in 2009/2010; comparison with data gathered in 1988 and 1999.

RESULTS

Ninety-four per cent (225/240) of CDTs responded; data on 242 teams were available from 1999 and 125 teams from 1988. Despite policy recommendations advocating the value of interdisciplinary team working, there was a decline in numbers of professionals working within the CDT multidisciplinary team. One-third of all teams reported a reduction in their funding over the last 5 years. However, specialist clinics provided increased. Teams reported patchy adoption of national initiatives designed to improve provision. Transition services were underdeveloped.

CONCLUSIONS

This comprehensive survey of UK CDT service provision, as well as national studies of the healthcare experience of families with a disabled child, shows that improvements in provision are required.

'Girls need to strengthen each other as a group': experiences from a gender-sensitive stress management intervention by youth-friendly Swedish health services--a qualitative study

BACKGROUND

Mental health problems among young people, and girls and young women in particular, are a well-known health problem. Such gendered mental health patterns are also seen in conjunction with stress-related problems, such as anxiety and depression and psychosomatic complaints. Thus, intervention models tailored to the health care situation experienced by young women within a gendered and sociocultural context are needed. This qualitative study aims to illuminate young women's experiences of participating in a body-based, gender-sensitive stress management group intervention by youth-friendly health services in northern Sweden.

METHODS

A physiotherapeutic body-based, health-promoting, gender-sensitive stress management intervention was created by youth-friendly Swedish health services. The stress management courses (n = 7) consisted of eight sessions, each lasting about two hours, and were led by the physiotherapist at the youth centre. The content in the intervention had a gender-sensitive approach, combining reflective discussions; short general lectures on, for example, stress and pressures related to body ideals; and physiotherapeutic methods, including body awareness and relaxation. Follow-up interviews were carried out with 32 young women (17-25 years of age) after they had completed the intervention. The data were analysed with qualitative content analysis.

RESULTS

The overall results of our interview analysis suggest that the stress management course we evaluated facilitated 'a space for gendered and embodied empowerment in a hectic life', implying that it both contributed to a sense of individual growth and allowed participants to unburden themselves of stress problems within a trustful and supportive context. Participants' narrated experiences of 'finding a social oasis to challenge gendered expectations', 'being bodily empowered', and 'altering gendered positions and stance to life' point to empowering processes of change that allowed them to cope with distress, despite sometimes continuously stressful life situations. This intervention also decreased stress-related symptoms such as anxiousness, restlessness, muscle tension, aches and pains, fatigue, and impaired sleep.

CONCLUSIONS

The participants' experiences of the intervention as a safe and exploratory space for gendered collective understanding and embodied empowerment further indicates the need to develop gender-sensitive interventions to reduce individualisation of health problems and instead encourage spaces for collective support, action, and change.

Stimulant and non-stimulant attention deficit/hyperactivity disorder drug use: total population study of trends and discontinuation patterns 2006-2009

OBJECTIVE

To explore the prevalence and discontinuation of dispensed medications for attention deficit/hyperactivity disorder (ADHD) drugs from 2006 to 2009.

METHOD

A total population cohort of all individuals aged 6-45 years, alive and registered as residents in Sweden during any calendar year from 2006 to 2009 (N = 5 149 791) included 41 700 patients dispensed with an ADHD drug (methylphenidate, atomoxetine, amphetamine, or dexamphetamine). The dispensing prevalence was calculated for each year, stratified on sex and age. A longitudinal analysis was also performed to compare the rates of treatment discontinuation across the strata.

RESULTS

The dispensing prevalence increased from 2.93 per 1000 in 2006 to 6.98 in 2009 (PR = 2.38, 95% CI = 2.34-2.43). The prevalence ratio (PR) was 3.40 for adults, 22-45 years old; 2.41 for adolescents, 15-21 years old; and 1.90 for children aged 6-14. The increase was also greater in women than in men (PR = 2.92 vs. 2.19). Patients aged 15-21 were the most likely to discontinue treatment; after 3 years and 11 months, 27% of those patients were still under treatment.

CONCLUSION

From 2006 to 2009, the number of prescriptions dispensed for ADHD drugs increased substantially. The rate of treatment discontinuation in the age interval 15-21 is higher than expected considering the persistence rates of the disorder.

The gap in transition between child and adolescent psychiatry and general adult psychiatry

BACKGROUND

During transition from child and adolescent psychiatry (CAP) to general adult psychiatry (GenP) young adults with mental illness face multilevel transitions along with a risk for disruption in continuity of care. The aim of this study was to describe professionals' experiences and views of the transition process from CAP to GenP.

METHOD

Data were collected through six focus group discussions with professionals from both CAP and GenP and analyzed by content analysis.

RESULTS

The results showed a gap in transition between CAP and GenP when different perspectives and care cultures meet in a complex process.

CONCLUSIONS

Cooperation, transition planning, and a mutual understanding of care can support young adults in transition from CAP to GenP.

Challenges in making the transition between pediatric and adult eating disorder programs: a qualitative study from the perspective of service providers

There is scant research regarding the transition from pediatric to adult eating disorder programs. This study aims to increase understanding of the factors that impede or facilitate successful service transition for individuals with anorexia nervosa moving from pediatric to adult eating disorder programs. Participants included service providers representing pediatric and adult eating disorder programs, in addition to community treatment providers in a large city. The following themes were identified: a) readiness, not age, should determine service transition; and b) implementation of interventions for facilitating transition from pediatric to adult eating disorder programs including appropriate medical follow-up. These findings delineate various factors that may help facilitate or interrupt a seamless and coordinated transition from pediatric to adult eating disorder programs.

Transition from child and adolescent to adult mental health services

This article explores key issues in relation to adolescence and the transition from Child and Adolescent Mental Health Services (CAMHS) to Adult Mental Health Services (AMHS). A national review of services revealed some concern and dissatisfaction regarding existing service provision. Nurses are employed in both of these services and are well placed to play a significant role during transition. The challenges and opportunities for services are explored with reference to key policy documents. Several factors contribute to better outcomes, including collaboration between CAMHS and AMHS, the young person and the family, aligning services with the young person's development and maturity, and approaching transition in a flexible way. These factors are highlighted with the use of a case study and with reference to the nurses' role.

Psychosocial assessments for young people: a systematic review examining acceptability, disclosure and engagement, and predictive utility

Adolescence and young adulthood are often turbulent periods in a person’s life. There are high rates of accidental deaths, suicide, mental health concerns, substance use, and sexual experimentation. Health care professionals need to conduct holistic assessments of clients in these developmental life stages to identify psychosocial risks and provide targeted early intervention and implement prevention strategies. The most useful psychosocial assessments for most health care professionals are those that can provide a complete picture of the young person’s life and circumstances. This article identifies psychosocial assessment instruments that can be used as an initial assessment and engagement tool with the general population of young people presenting for health care. We review the psychometric properties of each of the instruments, determining what type of instrument is most acceptable to young people, whether any can increase disclosure and improve engagement between young people and health professionals, and whether they have predictive utility. The search strategy complied with the relevant sections of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. A total of 89 published articles were identified, covering 31 different assessment instruments. Results indicated that those that were self-administered were most acceptable to young people, although it is unclear whether pen-and-paper or computer formats were preferred. Most psychosocial assessments can improve rates of disclosure and enhance engagement between young people and health professionals; however, worryingly, we found evidence that clinicians did not always respond to some of the most serious identified risks. Only for one instrument was there any mention of predictive utility. Future research should employ longitudinal approaches to determine the predictive utility of psychosocial assessments and focus on whether the use of new technologies can improve rates of disclosure.

Use of licit and illicit substances among adolescents in Brazil--a national survey

OBJECTIVE

We estimate the prevalence of alcohol, tobacco and illegal substance use in a national representative sample of adolescents. We also estimate how socio demographic characteristics, household environment and mental health are associated with substance misuse.

METHOD

This is a cross-sectional study using data from the first Brazilian National Alcohol Survey, which gathered information on the use of psychoactive substances in 761 participants aged 14 to 19 years old. Weighted logistic regression was used to calculate adjusted odds ratios.

RESULTS

More than half of the adolescents interviewed were regular alcohol users and one out of ten were abusers and/or dependents. Older male adolescents living in urban areas were more likely to present alcohol related disorders and to smoke. Age had an inverse association with illegal substance use. Smokers and those using illegal substances were more likely to report domestic violence while those with alcohol abuse/dependence were more likely to have depression.

CONCLUSIONS

The high prevalence of alcohol, tobacco and illicit substance consumption among Brazilian adolescents is staggering. Young males with mood disorders from urban areas are more at risk of developing alcohol disorders while illegal drug use is highly associated to household dysfunction in early life. Brazilian growing economy will possibly lead to increased levels of substance use among adolescents if new prevention measures are not implemented. The intensification of law enforcement strategies to reduce psychotropic substances access is required.

Navigating the transition from pediatric to adult eating disorder programs: perspectives of service providers

OBJECTIVE

This study aims to conduct qualitative research on the perspectives of service providers regarding the transition process from pediatric to adult specialized eating disorder tertiary care programs.

METHOD

Two focus groups with a diverse group of clinicians in pediatric and adult eating disorder programs and five qualitative interviews with clinicians in the community were conducted.

RESULTS

Three themes were identified as challenges during the transition process: (1) illness related factors (ambivalence and denial); (2) the interruption of normative adolescent developmental processes by the illness; and, (3) the impact of decreased parental involvement in the adult compared to pediatric eating disorder programs.

DISCUSSION

These themes were compared with empirical evidence on other chronic mental or physical health concerns for the purpose of identifying ways to facilitate a more successful service transition for young adults with anorexia nervosa. Future research and clinical implications are delineated.

Age of onset of mental disorders and use of mental health services: needs, opportunities and obstacles

PURPOSE OF REVIEW

In this review, we provide an update of recent studies on the age of onset (AOO) of the major mental disorders, with a special focus on the availability and use of services providing prevention and early intervention.

RECENT FINDINGS

The studies reviewed here confirm previous reports on the AOO of the major mental disorders. Although the behaviour disorders and specific anxiety disorders emerge during childhood, most of the high-prevalence disorders (mood, anxiety and substance use) emerge during adolescence and early adulthood, as do the psychotic disorders. Early AOO has been shown to be associated with a longer duration of untreated illness, and poorer clinical and functional outcomes.

SUMMARY

Although the onset of most mental disorders usually occurs during the first three decades of life, effective treatment is typically not initiated until a number of years later. There is increasing evidence that intervention during the early stages of disorder may help reduce the severity and/or the persistence of the initial or primary disorder, and prevent secondary disorders. However, additional research is needed on effective interventions in early-stage cases, as well as on the long-term effects of early intervention, and for an appropriate service design for those with emerging mental disorders. This will mean not only the strengthening and re-engineering of existing systems, but is also crucial the construction of new streams of care for young people in transition to adulthood.

Transition experiences of mental health service users, parents, and professionals in the United Kingdom: a qualitative study

OBJECTIVE

The aim of this study was to describe the experiences of child and adolescent mental health service (CAMHS) users, parents and professionals in relation to transition between CAMHS and adult mental health services (AMHS) in the United Kingdom.

METHODS

Young people were sampled from an observational study population of people reaching the transition boundary between CAMHS and AMHS. We thematically analyzed qualitative interviews with service users, parents and clinicians.

RESULTS

Eleven service users were interviewed and linked interviews were completed with parents (n=6), and responsible clinicians in CAMHS (n=3) and AMHS (n=6). Informal and gradual preparation, transfer planning meetings, periods of parallel care, and consistency in key-workers promoted positive experiences of transition. Transfers between AMHS, changes of key-worker and waiting lists were viewed negatively. Other life transitions, including changes in housing, pregnancy, physical illness, and the involvement of parents or other services were sometimes powerful extraneous influences on transition experiences.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

The cumulative effect of multiple transitions is a complex and unsettling experience for many service users. Service user experiences are more likely to be positive if healthcare transition is a gradual process, tailored to the young person's needs and managed in the context of the other simultaneous practical, developmental and psychosocial transitions. Transfer planning meetings and parallel care were valued by all parties and should be standard practice at transition. CAMHS and AMHS need to work jointly to improve the transition process in these ways in order to enhance the outcomes for young people.

Avoiding the 'twilight zone': recommendations for the transition of services from adolescence to adulthood for young people with ADHD

Attention deficit hyperactivity disorder (ADHD) is a common childhood disorder that frequently persists into adulthood. However, in the UK, there is a paucity of adult services available for the increasing number of young people with ADHD who are now graduating from child services. Furthermore, there is limited research investigating the transition of young people with ADHD from child to adult services and a lack of guidance on how to achieve this effectively. This paper reviews the difficulties of young people with ADHD and their families who are transitioning between services; we review transition from the child and adult health teams' perspectives and identify barriers to the transition process. We conclude with recommendations on how to develop transition services for young people with ADHD.

The same but different? Treatment of anorexia nervosa in adolescents and adults

A significant number of patients with anorexia nervosa have to be transferred from child and adolescent mental health services (CAMHS) to adult services. CAMHS and adult services differ in terms of therapeutic approach and the availability of specialist treatment. CAMHS treatment is often based around family interventions, which aim to help parents take control of their child's eating, and patients are often encouraged to 'externalise' the illness. Adult treatment tends to be based around individual therapy, and the patient is encouraged to take personal responsibility for change. The place of inpatient treatment is generally accepted for adults but there is uncertainty about its effectiveness for adolescents. Young people may find it difficult to negotiate the transition between services, and CAMHS and adult services need to work more closely together. Transitions should be carefully planned, with thorough preparation of both patients and their families.

Dose of Methylphenidate during Service Transition for Adults with ADHD

OBJECTIVES

We wanted to investigate how one element of the transitional process of adolescents to an adult ADHD service, namely the use of medication, fared when compared to the recommendations of national guidelines.

METHODS

We did a chart review of the dose of stimulants in a cohort of transitional patients after they were transferred to an adult ADHD service, whilst investigating if other variables such as severity of ADHD, age, gender and comorbidity played any role in determining the dose of stimulants at transition.

RESULTS

The dose of stimulants when calculated in mg/kg was almost half the recommended whist the patients were also severely symptomatic. Reported comorbidity with Autistic Spectrum Disorders was also very high.

CONCLUSIONS

A handover approach of adolescents with ADHD to an adult service, may hide gaps at least as far as prescribing is concerned. This gap may need considerable resources to address successfully. We suggest that establishing transitional processes may help minimise this problem.

Transition to adulthood: the critical period for pre-emptive, disease-modifying care for schizophrenia and related disorders

There is an urgent need and a global opportunity to rethink not only the dominant research paradigms in etiological research but also to invest in less constrained strategies which cut across the existing diagnostic silos to seek out common risk factors, late as well as early neurodevelopmental processes, pathophysiologies, and novel treatment strategies. The high-quality research presented in this special issue of Schizophrenia Bulletin makes a compelling case for such a rethink. While there is still a genuine disconnect between our understanding of the complex and dramatic brain changes that occur during the transition to adulthood and the concurrent surge in incidence of mental ill-health, there is no doubt that a much more serious focus on the perionset stage of clinical disorders in young people with their rapidly evolving brains, social environments, and life trajectories could be extremely productive. Research access to these early stages of illness would be catalyzed by the widespread construction of engaging stigma-free portals and clinical scaffolding appropriate for young people in the 21st century. The latter are urgently required to supersede traditional models of care, which have served both patients and families so poorly, and equally have failed to unlock a deeper understanding of the origins and progression of potentially serious mental disorders.

Neurobiology and phenotypic expression in early onset schizophrenia

AIM

Early-onset schizophrenia (onset before adulthood) is a rare and severe form of the disorder that shows phenotypic and neurobiological continuity with adult-onset schizophrenia. Here, we provide a synthesis of keynote findings in this enriched population to understand better the neurobiology and pathophysiology of early-onset schizophrenia.

METHODS

A synthetic and integrative approach is applied to review studies stemming from epidemiology, phenomenology, cognition, genetics and neuroimaging data. We provide conclusions and future directions of research on early-onset schizophrenia.

RESULTS

Childhood and adolescent-onset schizophrenia is associated with severe clinical course, greater rates of premorbid abnormalities, poor psychosocial functioning and increased severity of brain abnormalities. Early-onset cases show similar neurobiological correlates and phenotypic deficits to adult-onset schizophrenia, but show worse long-term psychopathological outcome. Emerging technological advances have provided important insights into the genomic architecture of early-onset schizophrenia, suggesting that some genetic variations may occur more frequently and at a higher rate in young-onset than adult-onset cases.

CONCLUSIONS

Clinical, cognitive, genetic and imaging data suggest increased severity in early-onset schizophrenia. Studying younger-onset cases can provide useful insights into the neurobiological mechanisms of schizophrenia and the complexity of gene-environment interactions leading to the emergence of this debilitating disorder.

Organizational capacity to deliver effective treatments for children and adolescents

Treatment and services research in the general medical sector has emphasized the importance of addressing organizational capacity to improve interventions for patients with chronic conditions. Efficacious interventions for child and adolescent mental disorders without substantial enhancements in mental health organizational capacity will not result in improvements for children. This paper (a) lists some organizational enhancements that have resulted in improved medical care, (b) briefly underscores recent market trends such as state healthcare reform efforts, increased use of electronic records and contracting initiatives that push consolidation of agencies, and (c) describes one example of the organizational development of child behavioral services that will enhance treatment delivery.

Process, outcome and experience of transition from child to adult mental healthcare: multiperspective study

BACKGROUND

Many adolescents with mental health problems experience transition of care from child and adolescent mental health services (CAMHS) to adult mental health services (AMHS).

AIMS

As part of the TRACK study we evaluated the process, outcomes and user and carer experience of transition from CAMHS to AMHS.

METHOD

We identified a cohort of service users crossing the CAMHS/AMHS boundary over 1 year across six mental health trusts in England. We tracked their journey to determine predictors of optimal transition and conducted qualitative interviews with a subsample of users, their carers and clinicians on how transition was experienced.

RESULTS

Of 154 individuals who crossed the transition boundary in 1 year, 90 were actual referrals (i.e. they made a transition to AMHS), and 64 were potential referrals (i.e. were either not referred to AMHS or not accepted by AMHS). Individuals with a history of severe mental illness, being on medication or having been admitted were more likely to make a transition than those with neurodevelopmental disorders, emotional/neurotic disorders and emerging personality disorder. Optimal transition, defined as adequate transition planning, good information transfer across teams, joint working between teams and continuity of care following transition, was experienced by less than 5% of those who made a transition. Following transition, most service users stayed engaged with AMHS and reported improvement in their mental health.

CONCLUSIONS

For the vast majority of service users, transition from CAMHS to AMHS is poorly planned, poorly executed and poorly experienced. The transition process accentuates pre-existing barriers between CAMHS and AMHS.