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

Practitioner Review: Continuity of mental health care from childhood to adulthood for youths with ADHD - who, how and when?

Many youths with attention-deficit/hyperactivity disorder (ADHD) experience significant long-term impairment and may develop concurrent mental and somatic health difficulties as adults. This is associated with burden and costs for the individual and society which could be prevented through continued support in youth. Yet, only few young people transition to adult mental health services for ongoing care in different countries worldwide. We provide an overview on current transition practices, highlighting the gaps in knowledge and the barriers to effective service transitioning, while considering the large geographical variation in available guidelines and service provision. For ease of use, this review is organized in a question-and-answer format covering different aspects of the transition process and considering both service users' and clinicians' perspectives. Consensus is needed to identify those that require continued care, the optimal timing to arrange transition, and the most suitable services. Finally, we discuss cost-effectiveness of transition practices, consider examples of best practice, and propose recommendations on how to improve transitional care, including the importance of service users' input into transition planning.

Turning 18 in mental health services: a multicountry qualitative study of service user experiences and views

BACKGROUND

Worldwide, the division between Child and Adolescent Mental Health Services (CAMHS) and Adult Mental Health Services (AMHS) has frequently resulted in fragmented care with an unprepared, non-gradual transition. To improve continuity of care and other service transition experiences, service user input is essential. However, such previous qualitative studies are from a decade ago or focused on one mental disorder or country. The aim of the present study was to learn from service users' transition experiences and suggested improvements.

METHODS

Semi-structured interviews were held with young people aged 18-24 and/or parents/caregivers in the United Kingdom, Ireland, the Netherlands and Croatia. Inclusion was based on the experience of specialist mental health care before and after turning 18. Thematic analysis of transcribed and translated interview transcripts was performed using ATLAS.ti 9.

RESULTS

Main themes of service user experiences included abrupt changes in responsibilities, various barriers and a lack of preparation, communication and ongoing care. Young people expressed a great need for continuity of care. Their suggestions to improve transitional care included early and adequate preparation, joint working, improved communication from and between services, overlapping services, staying at CAMHS for longer and designated youth mental health teams.

CONCLUSIONS

Young people who experienced care before and after turning 18 suggested either altering the age limits of services or ensuring early preparation and communication regarding the transition and finding AHMS. This communication should include general changes when turning 18. Further considerations include increasing collaboration and overlap between CAMHS and AMHS.

Transgender Youth Readiness for Health Care Transition: A Survey of Youth, Parents, and Providers

Purpose

The purpose of this study was to identify health care transition (HCT) readiness and skills among transgender youth transitioning gender-affirming care from pediatric to adult providers.

Methods

A convenience sample of youth, 14-21 years old, their parents, and health care providers recruited from a multidisciplinary transgender youth clinic in 2019 completed a modified version of the Got Transition readiness assessment with elements specific to gender-affirming care. Youth assessed their own readiness, parents assessed their child's readiness, and providers assessed their transgender patients' readiness overall.

Results

Twenty-nine youth (mean age 17.0 years), 26 parents, and 5 health care providers participated. Ratings of the overall importance of preparing for HCT were similar across all participant groups, and there were few disagreements on the importance of individual skills included in the readiness assessment. Ratings of overall HCT readiness were similar for youth regardless of age, while parents of younger youth (<18 years old) reported lower readiness than did parents of older youth. Youth rated their own competence in several skills higher compared with parents or providers, including knowledge of hormone therapy side effects. All groups of participants reported that youth most frequently needed assistance with scheduling appointments and keeping records of health information.

Conclusions

Survey of youth, parents, and providers suggests that youth and parents require additional support to navigate the HCT process, highlighting the importance of ongoing skills assessment and planning.

'It would help people to help me': Acceptability of digital phenotyping among young people with visual impairment and their families

Objectives

To explore the acceptability of an eHealth App for vision-related monitoring and symptom reporting among young people with a visual impairment and their parents.

Methods

Qualitative investigation using virtual semi-structured focus groups (via Zoom software) of seven young participants with a genetic eye disorder including inherited retinal disease and structural eye abnormalities (e.g. microphthalmia), and 7 parents; all recruited from ocular genetic clinics at Moorfields Eye Hospital. Audio transcripts were analysed using thematic analysis.

Results

Data were coded into six key themes: (1) increased involvement in care, (2) opportunity for less hospital-centric care, (3) better representation of visual impairment in a real-world setting, (4) trust in a reputable service provider, (5) harnessing data for health purposes and (6) intended purpose of the app. Both young people and their families were accepting of an eHealth app and felt they would be empowered by greater involvement in their care plan, if privacy of the data was retained, and information was managed correctly. While parents endorsed the opportunity for mental health tracking, young people were hesitant towards its inclusion.

Conclusion

In summary, there was overall acceptability of an eHealth app among young people with a visual impairment and their parents. These findings will help to maximise the effective integration of digital phenotyping when monitoring and supporting young people experiencing sight loss.

Modification of an Intervention to Improve Adherence in Adolescents and Young Adults With Bipolar Disorder

Objective

Managing bipolar disorder (BD) is particularly challenging for adolescents and young adults (AYAs) ages 16 to 21. Few interventions exist that address self-management in AYAs with BD. Thus, this study aimed to modify the customized adherence enhancement behavioral intervention for AYAs through an iterative, patient-centered process.

Method

The Obesity-Related Behavioral Intervention Trials (ORBIT) model was used for intervention development. In phase 1a, adherence barriers and facilitators were identified to refine intervention content. Phase 1b occurred following curriculum modification to ensure that the modified intervention was relevant and usable by the target population. Data were collected via focus groups and interviews with AYAs with BD, parents, and providers. Transcripts were analyzed using directed content analysis.

Results

Phase 1a included focus groups/interviews with AYAs (n = 10), parents (n = 4), and providers (n = 9) who described the difficulties and successes in managing BD symptoms, improving adherence, and transitioning care from caregivers. Phase 1b included an advisory board composed of 8 phase 1a participants who provided feedback on modified session activities, module delivery, and curriculum. Phase 1b involved usability testing with new participants (n = 8), revealing the need for modifiable language based on developmental level, more engaging visual images, and confirmation that topics were salient to AYAs with BD.

Conclusion

Though sample sizes were small and not representative of the population of AYAs with BD, the ORBIT methodology informed the adaptation of the customized adherence enhancement intervention to improve adherence in AYAs with BD. Important next steps are to conduct a pilot randomized clinical trial of customized adherence enhancement for AYAs.

Transition from an adolescent to an adult eating disorder treatment centre: A qualitative investigation of the experience of inpatients with anorexia nervosa and their carers using interpretative phenomenological analysis

AIMS

To capture the subjective experience of eating disorder patients and their immediate family members in the transition between adolescent and adult treatment services and to explore how both groups make sense of this specific experience.

DESIGN

Qualitative study in the form of in-depth interviews using interpretative phenomenological analysis.

SETTINGS

Participants were recruited from a university department of a large psychiatric hospital specialising in eating disorders between July 2021 and September 2022.

PARTICIPANTS

A convenience sample of 18 participants was recruited, including 12 patients aged 19-30 years (m = 22.5, SD = 3.8) and six of their respective caregivers.

RESULTS

Four main themes were identified in relation to the participants' experience of transition to adult care: (1) the detailed description of the transition process, (2) the emotions associated with this experience, (3) the challenges encountered and (4) recommendations for improving the process. Two fundamental meaning-making processes emerged: the feeling of being "lost in transition" and the opportunity to "become an adult". The results highlighted the factors that characterise this experience for patients and their families, and the need for practical and psychological support during the transition process.

CONCLUSIONS

This study provides a unique insight into the experience of patients and their immediate family members regarding the transition from adolescent to adult care. It reveals the multidimensional impact of the transition experience and highlights the need for increased support for family members. These findings may provide new insights into interventions that promote successful transition and encourage rethinking the organisation of this crucial stage of the care pathway.

Assessing the feasibility of an intervention for adolescents and parents transitioning out of paediatric eating disorder services: A mixed methods study

OBJECTIVE

To assess the feasibility of a new intervention designed to support adolescents and parents in the transition from paediatric eating disorder (ED) treatment to adult mental health services.

METHOD

Pre-transition adolescents with EDs, and their parents, were invited to complete up to five transition intervention components over 3 months. A mixed methods design was used to assess intervention feasibility, comprised of acceptability and preliminary effectiveness. A single-arm pre-post design was used to collect and analyse quantitative survey and feasibility data. Individual qualitative interviews and written reflections were collected and analysed using content analysis.

RESULTS

This study yielded a 33% (10/31) recruitment rate and 68% (13/19) retention rate. On average, participants completed 75% of the expected components in under 3 months, with varied completion of each expected intervention component (40%-100%). Participants found the intervention convenient and helpful. Parents reported a significant decrease in guilt (Z = -2.02, p = 0.04, d = -0.83). By 1-month post-transition, three adolescents transitioned to interim supports and none started specialist adult treatment.

CONCLUSIONS

Although this transition intervention did not demonstrate adequate feasibility, its acceptability and effectiveness should be evaluated after an update based on participant feedback. Other solutions to bridge the transition gap for adolescents with EDs should continue to be identified.

CLINICAL TRIAL REGISTRATION NUMBER

NCT04888273.

The role of psychological distress, stigma and coping strategies on help-seeking intentions in a sample of Italian college students

BACKGROUND

Mental health issues are common among university students, but the latter are unlikely to seek professional help even when mental health services are available. Coping strategies, stigma and psychological distress are often considered as factors that can affect help-seeking intentions in university students.

METHODS

This study aimed to determine the role of coping strategies, stigma and psychological distress on the intentions to seek professional help for psychological problems. All students (N = 13,886) from an Italian medium-sized university were asked to participate in a multidimensional online survey and 3754 (27.1%) agreed to participate. A Structural Equation Modelling approach was applied to explore the simultaneous direct and indirect effects of distress, stigma and coping strategies on professional help-seeking intentions.

RESULTS

Results showed that students were not very likely to seek professional help and, through the Structural Equation Model, psychological distress was found to be positively correlated with coping strategies, which in turn was negatively associated with the stigma of seeking help. The latter was negatively associated with professional help-seeking intentions. These effects suggest that students with significant psychological distress use coping strategies to face the stigma of seeking help: the lower the stigma of seeking help, the higher the chance of developing intentions to seek professional help.

CONCLUSIONS

This study suggests the importance of implementing programs to encourage college students to seek help, including measures that foster a stigma-free environment, reduce psychological distress and promote the use of adaptive coping strategies. Interventions should be focused firstly on self-stigma and secondly on perceived stigma, taking into consideration the level of psychological distress and social stereotypes associated with mental disorders and help seeking behaviours. Programs about coping are also essential and should focus on promoting emotion-focused strategies and problem-focused strategies.

Transitions in mental health and addiction care for youth and their families: a scoping review of needs, barriers, and facilitators

INTRODUCTION

Transitional-aged youth (TAY) with mental health and/or addictions (MHA) concerns and their families experience significant challenges finding, accessing, and transitioning through needed MHA care. To develop appropriate supports that assist TAY and their families in navigating MHA care, their experiences of transitions in the MHA care system must be better understood. This scoping review identifies and explores the needs, barriers, and facilitators for TAY and their families when transitioning through MHA care.

METHODS

This scoping review commenced with a search of five relevant databases. Three research team members were involved in title, abstract, and full-text scanning and data extraction. Sources focusing on TAY anywhere between the ages of 12-29 years and meeting the study objectives were included. Extractions compiled background and narrative information about the nature and extent of the data. Analysis and synthesis of findings involved numerical description of the general information extracted (e.g., numbers of sources by country) and thematic analysis of narrative information extracted (e.g., family involvement in TAY help-seeking).

RESULTS

A total of 5894 sources were identified. Following title and abstract scanning, 1037 sources remained for full-text review. A total of 66 sources were extracted. Findings include background information about extracted sources, in addition to five themes that emerged pertaining to barriers and facilitators to access and transitions through care and the needs and roles of TAY and families in supporting help-seeking and care transitions: holistic supports, proactive preparation, empowering TAY and families, collaborative relationships, and systemic considerations. These five themes demonstrate approaches to care that can ensure TAY and families' needs are met, barriers are mitigated, and facilitators are enhanced.

CONCLUSION

This review provides essential contextual information regarding TAY with MHA concerns and their families' needs when seeking care. Such findings lend to an enhanced understanding of how MHA programs can support this population's needs, involve family members as appropriate, reduce the barriers experienced, and work to build upon existing facilitators.

[Transition from Child and Adolescent to Adult Psychiatry in a German Metropolitan Region: An Explorative Cross-Sectional Study]

CONCERN

In psychiatry, the transition phase presents a particular challenge. The study aims to investigate gaps in care during the transition to adult psychiatry.

METHODOLOGY

After a qualitative preliminary study, 100 patients with previous child and adolescent psychiatric treatment were interviewed in a standardised way about the utilisation behaviour, the need for help and the experience during, before and after the transition phase. The data were analysed descriptively and using interval estimation (probability of coverage).

RESULTS

A treatment gap of more than 3 months was documented in 75% of the patients*. The study showed that treatment interruption was experienced as a risk for further crises and that there was often a lack of information on further treatment options.

CONCLUSION

The transition from child and adolescent to adult psychiatric treatment is not seamless and requires professional support.

Where Do Neurodevelopmental Disorders Go? Casting the Eye Away from Childhood towards Adulthood

Neurodevelopmental disorders (NDDs) encompass a group of complex conditions with onset during the early developmental period. Such disorders are frequently associated with a number of neuropsychiatric features, the most prevalent ones being autism spectrum disorder, attention-deficit/hyperactivity disorder, intellectual disability, communication and specific learning disorders, and motor disorders. These conditions are characterized by wide genetic and clinical variability, and although they were previously conceptualized as childhood-limited disorders, NDDs are progressively being recognized as persistent conditions with a potentially relevant impact on the quality of life and overall functioning during adult life. In addition, emerging evidence seems to point towards the hypothesis of a neurodevelopmental continuum, according to which NNDs could portray different time-dependent outcomes, depending on the severity of the altered brain development. Despite representing lifelong phenotypes, they are often not promptly identified and/or managed in adulthood. In this regard, specific guidelines on clinical and therapeutic approaches for these conditions have not yet been delineated. In this view, future research investigations should be encouraged to broaden available knowledge, characterize the clinical course of NDDs across an individual’s lifespan, and better understand the patterns of aging-related concerns in adults with an NDD diagnosis. Additionally, considering the difficulties many young adults encounter while transitioning from childhood to adult mental health services, new, specific programs should be developed and existing programs should be implemented to improve the transition process and for the management of NDDs in adulthood.

Predictors of mental health service utilization as adolescents with attention deficit hyperactivity disorder transition into adulthood

BACKGROUND

Attention deficit hyperactivity disorder (ADHD) symptoms may persist into adulthood and are likely to cause great problems in young adults. To date, few studies have explored the characteristics of patients diagnosed with ADHD that might influence the utilization of adult mental health services (AMHS). We aimed to examine and identify predictive symptoms of AMHS.

METHODS

We analysed data from 114 participants diagnosed with ADHD from a cohort of adolescents recruited at the age of 12-17 years, who, at the time of data analysis, were over 18 years old.

RESULTS

Among AMHS users, hyperactivity/impulsivity measures were significantly more severe (t = 2.668, df = 112, p < .001), ADHD combined subtype diagnosis (χ²  = 4.66, df = 1, p = .031) was more frequent and dysregulation profile in the SDQ-P was also significantly higher (t = -2.497, df = 109, p = .014). However, the dysregulation profile did not remain statistically significant after controlling for type of AMHS contact.

CONCLUSIONS

Our findings suggest that adolescents with ADHD are more likely continue their care under AMHS if they present more severe symptoms of hyperactivity/impulsivity and emotional dysregulation. The better characterization of the patient profile will help clinicians to early identify groups at-risk and to tailor interventions and prevention strategies.

A cross-sectional examination of service complexity in youths with co-occurring autism spectrum disorder and psychiatric or medical diagnoses across service sectors

Introduction

Autism spectrum disorder (ASD) is a heterogeneous, life-long, and complex condition. Youth diagnosed with ASD require several supports addressing core symptoms associated with the disorder, but also those resulting from co-occurring mental and physical health conditions. As a result, their care is overseen by numerous professionals spanning various service sectors, but communication between sectors is hindered due to the absence of a standardized assessment system to identify and triage youth to services. A paucity of information surrounding this population's service use lingers and a siloed delivery system persists.

Methods

Using archival data collected from 1,020 youth between 12 and 18 years of age, this study explored service complexity among autistic youth with and without psychiatric and medical co-occurring conditions in Ontario, Canada. In doing so, a negative binomial regression was utilized to investigate which predisposing, enabling, and need variables were associated with service complexity.

Results

Results revealed that experiencing financial difficulties was not associated with service complexity. However, age, sex, caregiver distress, comorbidity, intellectual disability, and evaluated health status were significant predictors. More specifically, female youth and youth with distressed caregivers had greater mental health service complexity scores. Additionally, youth diagnosed with two or more conditions in addition to ASD who required longer durations of programming, controlling for other predictors, had greater mental health service complexity scores. Yet, youth with an intellectual disability had lower service complexity scores.

Discussion

Clinical implications of this study are discussed to inform future investments into mental health efforts for autistic youth.

Management of transitions to adult services for young people with eating disorders: survey of current practice in England

AIMS AND METHOD

The Royal College of Psychiatrists has published recommendations for managing transitions between child and adolescent mental health services (CAMHS) and adult services for eating disorders. A self-report questionnaire was designed to establish how many CAMHS teams meet these recommendations and was distributed to 70 teams providing eating disorders treatment in England.

RESULTS

Of the 38 services that participated, 31 (81.6%) reported a flexible upper age limit for treatment. Only 6 services (15.8%) always transferred young people to a specialist adult eating disorders service and the majority transferred patients to either a specialist service or a community mental health team. Most services complied with recommended provision such as a written transition protocol (52.6%), individualised transition plans (78.9%), joint care with adult services (89.5%) and transition support for the family (73.7%).

CLINICAL IMPLICATIONS

Services are largely compliant with the recommendations. It is a concern that only a small proportion of services are always able to refer to a specialist adult service and this is likely to be due to a relative lack of investment in adult services.

Leaving child and adolescent mental health services in the MILESTONE cohort: a longitudinal cohort study on young people's mental health indicators, care pathways, and outcomes in Europe

BACKGROUND

The configuration of having separate mental health services by age, namely child and adolescent mental health services (CAMHS) and adult mental health services (AMHS), might be a barrier to continuity of care that adversely affects young people's mental health. However, no studies have investigated whether discontinuity of care in the transition period affects mental health. We aimed to discern the type of care young people receive after reaching the upper age limit of their CAMHS and examine differences in outcomes at 24-month follow-up between young people receiving different types of care.

METHODS

To assess mental health in young people from 39 CAMHS in eight European countries (Belgium, Croatia, France, Germany, Italy, Ireland, the Netherlands, and the UK), we did a longitudinal cohort study. Eligible young people were CAMHS users up to 1 year younger than the upper age limit of their CAMHS or up to 3 months older, if they were still in CAMHS. Information on mental health service use, mental health problems (ie, using the Health of the Nation Outcome Scale for Children and Adolescents, Youth Self-Report and Adult Self-Report, DSM-5, and ICD-10), and sociodemographic characteristics were collected using self-reported, parent-reported, and clinician-reported interviews and questionnaires. Mixed models were applied to assess relationships between baseline characteristics, mental health service use, and outcomes.

FINDINGS

The MILESTONE cohort included 763 young people. The participants were 60·0% female (n=458) and 40·0% male (n=305), 90·3% White (n=578), and had a mean age of 17·5 years (range 15·2-19·6 years). Over the 24-month follow-up period, 48 young people (6·3%) actively withdrew from the study. For young people, the higher their scores on the Health of the Nation Outcome Scale for Children and Adolescents (p=0·0009) and Youth Self-Report and Adult Self-Report (p=0·046), and who had a clinical classification of severe mental illness (p=0·0033), had suicidal thoughts or behaviours or self-harm (p=0·034), used psychotropic medication (p=0·0014), and had a self-reported or parent-reported need for continued treatment (p&lt;0·0001) at baseline, were more likely to transition to AMHS or stay in CAMHS than to have care end. Overall, over the 24-month follow-up period, the mental health of young people improved, but 24·4% of young people reported an increase in problems calculated using the reliable change index, of whom 5·3% had a clinically relevant increase in problems. At 24-month follow-up, no differences in change in mental health problems since baseline were found between young people who used different types of care (CAMHS, AMHS, or no care).

INTERPRETATION

Although approximately half of young people reaching the upper age limit of their CAMHS stop using mental health services, this was not associated with a deterioration in their mental health. Young people with the most severe mental health problems are more likely to receive continued care. If replicated, our findings suggest investments in improving transitional care for all CAMHS users might not be cost-effective in times of rising health-care costs, but might be better targeted at a subgroup of young people with increasing mental health problems who do not receive continued treatment.

FUNDING

European Commission's 7th Framework Programme.

A Multi-Stakeholder Perspective on Factors Affecting Successful Transition to Adulthood for Youth with Severe Emotional Disturbances

This study elicited the perspectives of youth, caregivers, service providers and researchers to explore how communities can best support the transition to adulthood for youth ages 16-21 with mental health and functional impairments, who are at risk of disconnecting from health and human services. Framed by Relational Systems Evaluation (RSE) and Positive Youth Development (PYD), our study demonstrates the importance of engagement with youth experts. Group Concept Mapping (GCM), a collaborative multiphase mixed-methods approach, was used as a systematic process for participants to make meaning of qualitative data using multidimensional scaling and hierarchical cluster analysis (Kane and Trochim in Concept mapping for planning and evaluation, Sage Publications Inc., Thousand Oaks, 2007). Across all participant groups, Life Skills were perceived as highly important and highly feasible for a successful transition to adulthood. However, Positive Social Support & Connectedness were viewed as less important and less feasible by all groups. When examined closely, youth perspectives differed from caregiver and provider perspectives in the factors they prioritized and deemed feasible. Our findings have implications for community mental health services and positive youth development program practitioners.

Navigation for youth mental health and addictions: protocol for a realist review and synthesis of approaches and practices (The NavMAP standards project)

INTRODUCTION

Mental health and/or addiction (MHA) concerns affect approximately 1.2 million children and youth in Canada, yet less than 20% receive appropriate treatment for these concerns. Youth who do not receive appropriate support may disengage from care and may experience lasting MHA issues. Families of these youth also support them in finding and accessing care. Thus, system supports are needed to help youth and their families find and equitably access appropriate care. Navigation is an innovation in MHA care, providing patient-centred support and care planning that helps individuals and families overcome barriers to care. Despite the increasing availability of navigation services for youth with MHA concerns, practices and models vary, and no single source has synthesised evidence regarding approaches and outcomes for this population into comprehensive standards.

METHODS AND ANALYSIS

The proposed research will bring together evidence in youth MHA navigation, to establish this important system support as a factor that can enhance the integration and continuity of care for these youth. Our team, which includes researchers, administrators, clinical leads, an MHA navigator and youth and caregivers with lived experience, will be involved in all project stages. Realist Review and Synthesis methodology will be used, the stages of which include: defining scope, searching for evidence, appraising studies and extracting data, synthesising evidence and developing conclusions, and disseminating findings.

ETHICS AND DISSEMINATION

Ethics approval is not required, as the study involves review of existing data. Dissemination plans include scientific publications and conferences and online products for stakeholders and the general public.

Addressing the Treatment and Service Needs of Young Adults with Attention Deficit Hyperactivity Disorder

The transition from adolescence to adulthood is a complex period in which multiple changes take place (education, work, independent living, and social relations). This stage is especially difficult for adolescents suffering from attention deficit hyperactivity disorder (ADHD), who have to move on from child and adolescent mental health services to adult mental health services. This review analyzes developmental and environmental risk and protective factors as well as critical variables such as executive functioning and self-monitoring that influence the course of ADHD in transitional age youth and guide the priorities for an optimal transition of care. The influence of the COVID-19 pandemic is also discussed. We reflect on the unmet needs for an optimal transition of care and propose practice and policy recommendations to achieve this goal.

An Intervention to Promote Healthcare Transition Planning Among Pediatric Residents

PURPOSE

Poorly planned healthcare transition (HCT) from pediatric to adult-based care for adolescents and young adults with special healthcare needs (AYASHCN) is associated with increased morbidity and mortality. Most pediatricians and pediatric residents are not trained to assist AYASHCN with HCT planning. An electronic medical record-based Transition Planning Tool (TPT) was developed at a large children's hospital to guide provider-patient interactions around HCT planning. The purpose of this study was to evaluate an educational intervention to promote residents' use of the TPT.

METHODS

A multimodal (TPT training, demonstrations, use prompts, and case discussions) curriculum promoting the use of the TPT was developed and implemented within a one-month Adolescent Medicine Rotation. A prospective, nonrandomized, quasi-experimental design with Intervention and Historical Control groups was used. Forty-two residents received the intervention. Twenty-three Historical Control residents received minimal formal training in the TPT. Intervention Group residents completed prerotation/postrotation assessments measuring perceived importance of/comfort with HCT planning and self-reported HCT planning activities. TPT use was compared between the two groups.

RESULTS

Compared to the Historical Control Group, Intervention Group residents were significantly more likely to use the TPT (98% vs. 37%, p < .001) and had a higher mean number of uses (5.5 ± 3.0 vs. 2.6 ± 1.2, p < .001). Residents reported greater perceived importance of (p < .001) and engagement in (p < .001) transition planning activities after completing the intervention. Nearly all (91%) reported that their training increased their comfort in HCT planning.

CONCLUSIONS

A targeted intervention improved pediatric residents' use of the TPT and HCT planning activities.

The effect of learning to drum on behavior and brain function in autistic adolescents

SignificanceThere is an acknowledged need for improved service provision in the context of autism spectrum disorders. Previous studies have demonstrated the positive role drum training can play in improving behavioral outcomes for children and adolescents with emotional and behavioral difficulties. However, to date, none of these studies has explored how these behavioral changes translate at the neural level. Our study provides strong evidence that drumming not only reduces hyperactivity and inattention in autistic adolescents but also strengthens functional connectivity in brain regions responsible for inhibitory control and action outcome monitoring.

Characterization of multilevel influences of mental health care transitions: a comparative case study analysis

Purpose

Mental health care transitions are increasingly prioritized given their potential to optimize care delivery and patient outcomes, especially those focused on the transition from inpatient to outpatient mental health care. However, limited efforts to date characterize such mental health transition practices, especially those spanning multiple service setting contexts. Examination of key influences of inpatient to outpatient mental health care transitions across care contexts is needed to inform ongoing and future efforts to improve mental health care transitions. The current work aims to characterize multilevel influences of mental health care transitions across three United States-based mental health system contexts.

Methods

A comparative multiple case study design was used to characterize transition practices within the literature examining children’s, non-VA adult, and VA adult service contexts. Andersen’s (1995) Behavioral Health Service Use Model was applied to identify and characterize relevant distinct and common domains of focus in care transitions across systems.

Results

Several key influences to mental health care transitions were identified spanning the environmental, individual, and health behavior domains, including: community capacity or availability, cross-system or agency collaboration, provider training and experience related to mental health care transitions, client care experience and expectations, and client clinical characteristics or complexity.

Conclusions

Synthesis illustrated several common factors across system contexts as well as unique factors for further consideration. Our findings inform key considerations and recommendations for ongoing and future efforts aiming to plan, expand, and better support mental health care transitions. These include timely information sharing, enhanced care coordination and cross setting and provider communication, continued provider/client education, and appropriate tailoring of services to improve mental health care transitions.

Dialectical behaviour therapy 'Skills for Living' for young people leaving care: A qualitative exploration of participants' experiences

It is acknowledged that care leavers experience an accelerated transition into adulthood, despite often having complex psychosocial needs with limited support networks. The 'Skills for Living' programme was designed to improve the psychological wellbeing of care leavers and offers an adapted Dialectical Behaviour Therapy skills group as its primary intervention. This paper provides a qualitative evaluation of the programme. Semi-structured interviews were undertaken with 10 participants, and the data were analysed using thematic analysis (Braun & Clarke, 2006). Four key themes emerged: 'Initial Apprehension and Reluctance to Participate', 'Connection, Understanding and Validation', 'Confidence with Social Skills', and 'Emotional Acceptance and Self-Soothing'. Clinical implications and recommendations are discussed.

Demographic, clinical, and service-use characteristics related to the clinician's recommendation to transition from child to adult mental health services

PURPOSE

The service configuration with distinct child and adolescent mental health services (CAMHS) and adult mental health services (AMHS) may be a barrier to continuity of care. Because of a lack of transition policy, CAMHS clinicians have to decide whether and when a young person should transition to AMHS. This study describes which characteristics are associated with the clinicians' advice to continue treatment at AMHS.

METHODS

Demographic, family, clinical, treatment, and service-use characteristics of the MILESTONE cohort of 763 young people from 39 CAMHS in Europe were assessed using multi-informant and standardized assessment tools. Logistic mixed models were fitted to assess the relationship between these characteristics and clinicians' transition recommendations.

RESULTS

Young people with higher clinician-rated severity of psychopathology scores, with self- and parent-reported need for ongoing treatment, with lower everyday functional skills and without self-reported psychotic experiences were more likely to be recommended to continue treatment. Among those who had been recommended to continue treatment, young people who used psychotropic medication, who had been in CAMHS for more than a year, and for whom appropriate AMHS were available were more likely to be recommended to continue treatment at AMHS. Young people whose parents indicated a need for ongoing treatment were more likely to be recommended to stay in CAMHS.

CONCLUSION

Although the decision regarding continuity of treatment was mostly determined by a small set of clinical characteristics, the recommendation to continue treatment at AMHS was mostly affected by service-use related characteristics, such as the availability of appropriate services.

Prioritizing core components of successful transitions from child to adult mental health care: a national Delphi survey with youth, caregivers, and health professionals

Youth accessing mental health care often experience a disruption in care as they attempt to transition between child and adolescent mental health services (CAMHS) and adult mental health services (AMHS). Few studies have evaluated interventions seeking to improve the experience and outcomes of CAMHS-AMHS transitions, in part due to lack of consensus on what constitutes best practices in intervention success. As such, the aim of this study was to engage patients, caregivers, and clinicians to prioritize core components of successful CAMHS-AMHS transitions which can be used in the design or evaluation of transition interventions. As such, a Delphi study was conducted to determine core components of successful CAMHS-AMHS transitions. Guided by the principles of patient-oriented research, three balanced expert panels consisting of youth, caregivers, and clinicians ranked and provided feedback on the importance and feasibility of core components of CAMHS-AMHS transitions. Components endorsed as feasible or important with ≥ 70% agreement from any panel moved to the next round. As a result, a list of 26 core components of CAMHS-AMHS transitions has been refined which can be used in the design, implementation, or evaluation of interventions intended to improve transition experiences and outcomes for youth in mental health care. Youth and families were engaged in an expert advisory role throughout the research process, contributing their important perspectives to the design and implementation of this study, as well as interpretation of the findings.

Cohort profile: demographic and clinical characteristics of the MILESTONE longitudinal cohort of young people approaching the upper age limit of their child mental health care service in Europe

PURPOSE

The presence of distinct child and adolescent mental health services (CAMHS) and adult mental health services (AMHS) impacts continuity of mental health treatment for young people. However, we do not know the extent of discontinuity of care in Europe nor the effects of discontinuity on the mental health of young people. Current research is limited, as the majority of existing studies are retrospective, based on small samples or used non-standardised information from medical records. The MILESTONE prospective cohort study aims to examine associations between service use, mental health and other outcomes over 24 months, using information from self, parent and clinician reports.

PARTICIPANTS

Seven hundred sixty-three young people from 39 CAMHS in 8 European countries, their parents and CAMHS clinicians who completed interviews and online questionnaires and were followed up for 2 years after reaching the upper age limit of the CAMHS they receive treatment at.

FINDINGS TO DATE

This cohort profile describes the baseline characteristics of the MILESTONE cohort. The mental health of young people reaching the upper age limit of their CAMHS varied greatly in type and severity: 32.8% of young people reported clinical levels of self-reported problems and 18.6% were rated to be 'markedly ill', 'severely ill' or 'among the most extremely ill' by their clinician. Fifty-seven per cent of young people reported psychotropic medication use in the previous half year.

FUTURE PLANS

Analysis of longitudinal data from the MILESTONE cohort will be used to assess relationships between the demographic and clinical characteristics of young people reaching the upper age limit of their CAMHS and the type of care the young person uses over the next 2 years, such as whether the young person transitions to AMHS. At 2 years follow-up, the mental health outcomes of young people following different care pathways will be compared.

TRIAL REGISTRATION NUMBER

NCT03013595.

Experiences of transition from children's to adult's healthcare services for young people with a neurodevelopmental condition

Previous research has highlighted a lack of continuity of care when young people with a neurodevelopmental condition make the transition from children's to adult specialist healthcare services. A lack of planning, consistency, and availability of adult services has been found to lead to; increased anxiety, poor health outcomes, reduced support and some young people not receiving healthcare. The majority of transition research has focused on what health professionals consider important in the transition process, rather than focusing on the experiences of the young people and those closest to them. Our objective was to gather evidence from young people (and their families) who had experienced transition from children's to adult specialist healthcare services through semi-structured interviews. Volunteers were recruited from two London boroughs. All young people were aged between 18 and 25 years with a neurodevelopmental condition (Attention Deficit Hyperactivity Disorder, Autism Spectrum Disorder and/or an Intellectual Disability). Overall, we interviewed six young people with support from a family member. Five further family members were interviewed on behalf of the young person. In total, ten semi-structured interviews were transcribed verbatim and analysed using Interpretative Phenomenological Analysis. Four themes emerged from the analysis: (a) Parents as advocates, (b) Availability of adult's specialist health and social care services, (c) Lack of information sharing and (d) Transition as a binary, abrupt change. Our findings suggest the transition experience could be improved by changing service specifications to incorporate assessment and handover across the age range of 16-20 years. Additionally, statutory services should understand and provide the coordination role now offered by parents in transition. We suggest future research could evaluate the feasibility of a patient-owned online information sharing tool with information about relevant services for young people and their families.

Adult Provider Perspectives on Transition and Transfer to Adult Care: A Multi-Specialty, Multi-Institutional Exploration

PURPOSE

To identify barriers that transcend multiple adult care specialties and identify potential solutions.

DESIGN AND METHODS

Twenty-one adult care providers practicing in the specialty areas of internal medicine, family medicine, gastroenterology, endocrinology, and neurology participated in one of six semi-structured focus group interviews. Data were coded and analyzed according to the Socio-ecological Model of Adolescent/Young Adult Readiness for Transition (SMART).

RESULTS

Three themes and one subtheme emerged from the data. These fell within the beliefs/expectations, knowledge, access/insurance, and relationships (subtheme) domains of the SMART model. Family beliefs/expectations regarding the provider role, difficulty accessing reliable information, and limited access to mental health and behavioral providers reportedly affect providers' ability to provide optimal health care.

CONCLUSIONS

Adult providers identified several barriers affecting their ability to care for newly transferred patients. Increased education of families and improved methods of communication between providers were recommended. Barriers related to access and insurance are common and require larger systems-level collaborations between health care systems and payor sources.

PRACTICAL IMPLICATIONS

Some recommendations (e.g., educating families on the distinct roles of the PCP vs. specialist, highlighting new treatment opportunities in adult care, conveying trust and endorsing the new provider), represent concrete steps pediatric providers can immediately take to improve transfer. Other steps will require forging bridges across the pediatric and adult care world to expand patient access to medical, mental health, and behavioral services.

Impending Transition From Pediatric to Adult Health Services: A Qualitative Study of the Experiences of Adolescents With Eating Disorders and Their Caregivers

Background: There is a dearth of research that identifies pediatric to adult health care transition practices that yield positive outcomes for young people with eating disorders (EDs). Further, adolescent and caregiver perspectives are poorly understood and underrepresented in the literature. The purpose of this study, focused on the impending transition from pediatric to adult health services, was twofold: (a) to identify adolescent and caregiver perspectives of barriers and facilitators of a successful transition for adolescents with EDs; and (b) to understand adolescent and caregiver suggestions of interventions for a successful transition. Design/Method: We recruited five adolescents with EDs who were about to be transferred out of pediatric care as well as their caregivers. We conducted a qualitative study in accordance with the principles of interpretive description. Through conducting semi-structured, in-depth interviews with adolescents and caregivers, we investigated their knowledge about health system transitions and anticipated experiences. We identified participants' perceptions of barriers and facilitators regarding a successful transition, as well as their recommendations to improve the transfer of care. Results: Participants possessed a limited understanding of transition processes despite the fact that they were about to be transferred to adult care. From our analyses, the following themes were identified as barriers during the transition process: re-explaining information to adult healthcare providers, lack of professional support while waiting for uptake into the adult health system, and late timing of transition of care discussions. Both adolescents and caregivers expressed that involvement of parents and the pediatric healthcare team helped to facilitate a successful transfer of care. In addition, participants expressed that the implementation of a Transition Coordinator and Transition Passport would be helpful in facilitating a seamless transfer between systems of care. Discussion: These findings demonstrate a significant gap in the system and highlight the importance of developing interventions that facilitate a successful transition. The themes that emerged from this study can inform the development of interventions to facilitate a coordinated transition from pediatric to adult health services for adolescents with EDs.

Predicting Child-to-Adult Community Mental Health Service Continuation

Serious mental health conditions peak in prevalence and incidence during the transition to adulthood (approximately ages 16-25). Young adults are at high risk for discontinuation of care when no longer eligible for child mental health services. This study uses state administrative data to examine service continuation among those aging out of child system services in Texas (N = 3135). Most (63.5%) did not enroll in adult services following their 18th birthday. Binary logistic regression analyses found that significant predictors of child-to-adult service continuation included (1) a serious primary mental health diagnosis (i.e., schizophrenia, bipolar disorder, major depressive disorder), (2) risks to self and others, and (3) number of prior-year mental health services received. These findings suggest that historical mental health policies and practices may contribute to service disconnection at age 18 in Texas. Implications for mental health policy and system reform locally and nationally are discussed.

A Retrospective Evaluation of a Pilot Youth Community Assessment and Treatment Service

OBJECTIVE

Targeted, highly accessible early intervention for youths with emerging and complex psychiatric presentations is increasingly needed. The Youth Community Assessment and Treatment Team (YCATT) multidisciplinary service was established to provide intensive intervention for youths in Perth, Australia.

METHODS

The authors conducted a retrospective evaluation to examine YCATT's impact on emergency department (ED) visits, psychiatric inpatient admissions, and provision of care for youths in the transition period between adolescent and adult psychiatric services. Demographic, clinical, and service utilization data for all referrals over the pilot period (2016-2017) were collected and analyzed with descriptive statistics.

RESULTS

During the pilot period, 308 referrals were accepted. All referred youths had a trauma history and presented with acute or complex conditions, and most (66%) were between 16 and 18 years old. The admission rate to a psychiatric inpatient unit was <7%. Of 61 youths specifically referred to YCATT as an alternative to psychiatric admission, 90% were successfully diverted from psychiatric or ED admission. After discharge from YCATT, youths had improved scores on the Health of the Nations Outcome Scale and 10-item Kessler Psychological Distress Scale.

CONCLUSIONS

These findings suggest that YCATT is an accessible and effective service for the population of transition-age youths. It appears that YCATT, in collaboration with other community services, contributed to diverting psychiatric inpatient admissions, facilitated outpatient treatment, and enabled continuity of care for vulnerable youths. The results underscore the need for more accessible, individualized treatment approaches for youths who transition to adulthood.

Central nervous system disease with JC virus infection in adults with congenital HIV

OBJECTIVE

The aim of this study was to describe the natural history of individuals with congenital HIV who develop JC virus (JCV) infection of the central nervous system (CNS).

METHODS

We retrospectively evaluated individuals with congenital HIV who met criteria for progressive multifocal leukoencephalopathy (PML) or JCV granule cell neuronopathy (JCV GCN) at three major healthcare centres in the northeast USA. Data on adherence to combined antiretroviral therapy (cART), neurologic symptoms, serum markers of immunity and HIV infection, cerebrospinal fluid (CSF) analyses, radiographic features, modified Rankin Scale (mRS) scores and survival were collected from the electronic medical record up to a censoring date of 1 August 2020.

RESULTS

Among 10 adults with congenitally acquired HIV, nine were diagnosed with definitive PML and one was diagnosed with probable JCV GCN. Individuals presented at the time of their PML or JCV GCN diagnosis with a mean mRS of 2.0 (standard deviation 1.0). A premorbid mRS was documented for six patients and was zero in all cases. The most common risk factor was confirmed cART nonadherence in nine individuals. Five individuals with PML and one with JCV GCN died, with a latency from symptom onset to death of approximately 3 months for three individuals, and approximately 2 years for the remaining two.

CONCLUSION

Youth-adulthood transition is a high-risk point for dropping off from medical care. The study of this timepoint in people living with HIV could help inform effective care in these individuals.

A certificate in youth psychiatry: meeting the training needs of psychiatrists

OBJECTIVE

This paper provides the rationale for the development of sub-specialty training in youth psychiatry.

METHOD

Training needs for youth psychiatry are discussed and the opportunities provided by sub-specialisation in youth psychiatry are presented.

RESULTS

The majority of mental disorders have their onset prior to 25 years. There has been substantial recent growth in services to meet the clinical needs of young people. The development of these services has exposed gaps in current training for psychiatrists, which varies considerably between child and adolescent, and adult psychiatry. Competencies acquired by psychiatrists in youth mental health are non-standardised, which may hinder optimal care.

CONCLUSIONS

Sub-specialty training in youth psychiatry is needed to meet workforce demands. The development of a certificate in youth psychiatry, by the RANZCP Section for Youth Mental Health, is underway. This will complement existing training and provide trainees and psychiatrists the opportunity to develop specialist skills in the provision of mental health care for young people negotiating the transition between adolescence and adulthood.

Inequalities in referral pathways for young people accessing secondary mental health services in south east London

Differences in health service use between ethnic groups have been well documented, but little research has been conducted on inequalities in access to mental health services among young people. This study examines inequalities in pathways into care by ethnicity and migration status in 12-29 years old accessing health services in south east London. This study analyses anonymized electronic patient record data for patients aged 12-29 referred to a south east London mental health trust between 2008 and 2016 for an anxiety or non-psychotic depressive disorder (n = 18,931). Multinomial regression was used to examine associations between ethnicity, migration status, and both referral source and destination, stratified by age group. Young people in the Black African ethnic group were more likely to be referred from secondary health or social/criminal justice services compared to those in the White British ethnic group; the effect was most pronounced for those aged 16-17 years. Young people in the Black African ethnic group were also significantly more likely to be referred to inpatient and emergency services compared to those in the White British ethnic group. Black individuals living in south east London, particularly those who identify as Black African, are referred to mental health services via more adverse pathways than White individuals. Our findings suggest that inequalities in referral destination may be perpetuated by inequalities generated at the point of access.

Transitional psychiatry in the Netherlands: Experiences and views of mental health professionals

BACKGROUND

The majority of psychopathology emerges in late adolescence and continues into adulthood. Continuity of care must be guaranteed in this life phase. The current service configuration, with a distinction between child/adolescent and adult mental health services (CAMHS and AMHS), impedes continuity of care.

AIM

To map professionals' experiences with and attitudes towards young people's transition from CAMHS to AMHS and the problems they encounter.

METHODS

An online questionnaire distributed among professionals providing mental health care to young people (15-25 years old) with psychiatric disorders.

RESULTS

Five hundred and eighteen professionals completed the questionnaire. Decision-making regarding transition is generally based on the professional's own deliberations. The preparation was limited to discussing changes with the adolescent and parents. Most transition-related problems are experienced in CAMHS, primarily with regard to collaboration with AMHS. Respondents report that the developmental age should be leading in the transition-decision making process and that developmentally appropriate services are important in bridging the gap.

CONCLUSION

Professionals in CAMHS and AMHS experience problems in the preparation of, and the collaboration during transition. The problems are related to coordination, communication and rules and regulations. Professionals attach importance to improvement through an increase in flexibility and more specialist services for youth.

The transition from children’s services to adult services for young people with attention deficit hyperactivity disorder: the CATCh-uS mixed-methods study

Background

Attention deficit hyperactivity disorder was previously seen as a childhood developmental disorder, so adult mental health services were not set up to support attention deficit hyperactivity disorder patients who became too old for child services. To our knowledge, this is the first in-depth study of the transition of attention deficit hyperactivity disorder patients from child to adult health services in the UK.

Objectives

Our objectives were to explore how many young people with attention deficit hyperactivity disorder are in need of services as an adult, what adult attention deficit hyperactivity disorder services are available and how attention deficit hyperactivity disorder stakeholders experience transition from child to adult services.

Design

An interactive mixed-method design was adopted with three study streams: (1) a 12-month surveillance study with 9-month follow-up to find out how many young people required ongoing medication when they were too old for child services (929 surveys completed by children’s clinicians); (2) a mapping study to identify and describe services for young adults with attention deficit hyperactivity disorder (2686 respondents to online surveys for patients and health workers and freedom of information requests to service providers and commissioners); and (3) a qualitative study to explore key stakeholders’ experiences of transition from child to adult services (144 interviews with 64 attention deficit hyperactivity disorder patients, 28 parents and 52 health clinicians; 38 working in child or adult secondary health services and 14 general practitioners). Members of the public advised at each stage of the study.

Results

When corrected for non-response and case ascertainment, the annual number of young people with an ongoing need for medication for attention deficit hyperactivity disorder lies between 270 and 599 per 100,000 people aged 17–19 years. Among 315 individuals eligible for transition, 64% were accepted, but only 22% attended their first adult services appointment. Our interactive map describes 294 unique services for adults with attention deficit hyperactivity disorder across the UK, of which 44 are ‘dedicated’ attention deficit hyperactivity disorder services. Few services provide the full range of recommended provision; most focus on diagnosis and medication. Services are unevenly distributed across the UK, with nearly all ‘dedicated’ services being in England. Exploring stakeholders’ experiences revealed how invested the stakeholders are in continuing attention deficit hyperactivity disorder treatment and how the architecture of services affects transition. An association between attention deficit hyperactivity disorder, education and continuance of medication into young adulthood, plus parent involvement and feeling prepared for transition and adult life with attention deficit hyperactivity disorder, influenced investment. However, even with investment, how accessible adult services are, how patient needs fit with the remit of the adult service and the level of patient information available affect transition outcomes. The results also highlight how general practitioners can end up as care co-ordinators during transition by default.

Limitations

Transition estimates were based on those who want medication, so these indicate a minimum level of need.

Conclusions

Few of those who need ongoing support for attention deficit hyperactivity disorder successfully transfer to adult services, and a small proportion of those who transfer experience optimal transitional care. Adult attention deficit hyperactivity disorder service provision is patchy. Even among ‘dedicated’ services, few provide the whole range of National Institute for Health and Care Excellence-recommended treatments.

Future work

We need to evaluate various models of transitional care and adult attention deficit hyperactivity disorder provision, as well as develop and evaluate psychosocial interventions for young people and adults with attention deficit hyperactivity disorder.

Trial registration

Current Controlled Trials ISRCTN12492022.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 42. See the NIHR Journals Library website for further project information.

The needs and service preferences of caregivers of youth with mental health and/or addictions concerns

BACKGROUND

Caregivers experience significant strains as a result of navigating the complex mental health and/or addiction (MHA) system for their youth with MHA issues. We examined the characteristics of Ontario families with youth with MHA issues and their service needs.

METHODS

A cross-sectional survey study investigated the characteristics and service needs of families with youth with MHA issues across the province of Ontario, Canada. A total of 840 caregivers were recruited.

RESULTS

259 participants (Mage = 45.94, SD = 7.11) identified as caregiving for at least one youth with MHA issues. The majority of the participants were female (70.7%), married (73.4%), and completed at least some college/Bachelor degree (59.1%). The mean age of youth was 16.72 years (SD = 5.33) and the most frequently reported diagnoses were Depression (30.1%), ADHD (27.8%) and Generalized Anxiety Disorder (21.2%). Regression results demonstrated that presently accessing services, presently seeking services, and higher levels of barriers MHA services were significantly predictive of identifying navigation as helpful for finding appropriate MHA services (χ2(7) = 28.69, p < .001, Nagelkerke R2 = .16). Furthermore, presently accessing services was significantly predictive of identifying case management as helpful (χ2(7) = 29.59, p < .001, Nagelkerke R2 = .156), and of identifying a primary healthcare provider as helpful (χ2(7) = 38.75, p < .001, Nagelkerke R2 = .197) for finding appropriate MHA services.

CONCLUSION

Identifying the nature and extent of youth MHA issues, service needs, and family preferences can inform the development of services that address families' needs and lend vital support for accessing services within a complex system.

Challenges during the transition from child and adolescent mental health services to adult mental health services

The transition from child and adolescent to adult mental health services for young people with mental health problems is of international concern. Despite the high prevalence of mental disorders during adolescence and their tendency to continue during adulthood, the majority of young people do not experience continuity of care. The aim of this review paper is to unravel the complexity of transitional mental healthcare to clinicians, policy makers and mental health service managers, and to address challenges to a smooth transition process at all levels.

Digital Game Interventions for Youth Mental Health Services (Gaming My Way to Recovery): Protocol for a Scoping Review

Background

Digital or video games are played by millions of adolescents and young adults around the world and are one of the technologies used by youths to access mental health services. Youths with mental health problems strongly endorse the use of technologies, including mobile and online platforms, to receive information, support their treatment journeys (eg, decision-making tools), and facilitate recovery. A growing body of literature explores the advantages of playing digital games for improving attention span and memory, managing emotions, promoting behavior change, and supporting treatment for mental illness (eg, anxiety, depression, or posttraumatic stress disorder). The research field has also focused on the negative impact of video games, describing potential harms related to aggression, addiction, and depression. To promote clarity on this matter, there is a great need for knowledge synthesis offering recommendations on how video games can be safely and effectively adopted and integrated into youth mental health services.

Objective

The Gaming My Way to Recovery scoping review project assesses existing evidence on the use of digital game interventions within the context of mental health services for youths (aged 11-29 years) using the stepped care model as the conceptual framework. The research question is as follows: For which youth mental health conditions have digital games been used and what broad objectives (eg, prevention, treatment) have they addressed?

Methods

Using the methodology proposed by Arksey and O’Malley, this scoping review will map the available evidence on the use of digital games for youths between 11 and 29 years old with mental health or substance use problems, or both.

Results

The review will bring together evidence-based knowledge to assist mental health providers and policymakers in evaluating the potential benefits and risks of these interventions. Following funding of the project in September 2018, we completed the search in November 2018, and carried out data screening and stakeholder engagement activities during preparation of the protocol. We will conduct a knowledge synthesis based on specific disorders, treatment level and modality, type of service, population, settings, ethical practices, and user engagement and offer recommendations concerning the integration of video game technologies and programs, future research and practice, and knowledge dissemination.

Conclusions

Digital game interventions employ unique, experiential, and interactive features that potentially improve skills and facilitate learning among players. Digital games may also provide a new treatment platform for youths with mental health conditions. Assessing current knowledge on video game technology and interventions may potentially improve the range of interventions offered by youth mental health services while supporting prevention, intervention, and treatment.

International Registered Report Identifier (IRRID)

PRR1-10.2196/13834

Relais entre pédopsychiatrie et psychiatrie d’adulte : évaluation et propositions

Le relai de la pédopsychiatrie à la psychiatrie d’adulte est un processus de transition au sein du parcours de soins qui devrait s’inscrire dans une continuité respectant le développement individuel du patient. Il représente une étape fondamentale mais délicate du fait des différences d’organisation entre la psychiatrie infanto–juvénile et la psychiatrie d’adulte. Le risque principal est la rupture thérapeutique. Cette étape s’inscrit dans les priorités du plan stratégique de santé de l’Agence régionale de santé du Languedoc-Roussillon publié en avril 2011. Au centre hospitalier de Montpellier, nous avons étudié rétrospectivement la mise en œuvre de 31 relais réalisés entre 2008–2009 afin de les comparer aux recommandations de la littérature et de proposer des axes d’amélioration. Les patients de l’étude ont en moyenne 16 ans lors de la transition et c’est d’ailleurs ce critère d’âge qui motive à lui seul 51 % des demandes de relai. Les ruptures thérapeutiques sont rares (6 %), cependant un délai de 3 mois sans suivi entre les deux prises en charge est retrouvé pour 48 % des patients. Les praticiens expriment régulièrement des difficultés pour communiquer et pour organiser les relais. Les principaux critères de qualité manquants et donc à améliorer sont :

– une période de soins parallèles avec un travail conjoint entre les soignants de pédopsychiatrie et de psychiatrie d’adulte (critère absent dans 81 % des cas) ;

– une rencontre impliquant les deux équipes et le patient avec sa famille (critère absent dans 87 % des cas). Un protocole local de mise en œuvre des relais a été validé sur le pôle de psychiatrie suite à cette étude et sera diffusé auprès des psychiatres d’enfants et d’adultes afin d’améliorer leur collaboration. L’objectif serait de faire tomber les barrières organisationnelles et d’âge pour centrer le processus de transition sur les spécificités cliniques et environnementales de chaque patient.

No boundaries: a 2 year experience in a specialized youth mental health care program in the Netherlands

AIM

Young people around the age of 18 receiving mental health care usually face the transition from child and adolescent (CAMHS) to adult mental health services (AMHS) bringing the risk of disruption in continuity of care. Recognizing the importance of early intervention in this vulnerable life-period, this study aims to emphasize the importance of a client-centred approach and continuity of care for this age group. For a deeper understanding of the specific needs of this group, the working method of a Dutch youth mental health (YMH) team working in a secondary mental health care setting is described, including some clinical characteristics and treatment results of patients who accessed this service.

METHODS

Data consist of a detailed description of the working method of the YMH team combined with clinical characteristics of all patients aged 15-25 years accessing the services of the YMH team over a two-year period.

RESULTS

The YMH team incorporated suggestions of earlier research into a client centred treatment. Key elements were multidisciplinary meetings, transcending diagnosis, flexibility and collaboration with other care providers. Clinical records showed a complex patient population and significant treatment effect.

CONCLUSIONS

The group of emerging adults accessing the YMH team can be described as a patient group with a high diversity and complexity of disorders and problems. Continuity of care was met when patients turned 18, allowing treatments to be successfully performed by the same team of professionals using a client-centred approach.

Identifying core components and indicators of successful transitions from child to adult mental health services: a scoping review

The aim of this scoping review was to identify the core components of interventions that facilitate successful transition from child and adolescent mental health services to adult mental health services. In the absence of rigorous evaluations of transition program effectiveness for transitioning youth with mental health care needs, these core components can contribute to informed decisions about promising program and intervention strategies. This review examined data from 87 peer-reviewed and non-academic documents to determine the characteristics that support the transition process and to identify opportunities for system and program improvement. Data were extracted and synthesized using a descriptive analytic framework. A major finding of this review is a significant lack of measurable indicators in the academic and gray literature. This review did identify 26 core components organized within the framework of the six core elements of healthcare transitions. Policy makers, practitioners, and administrators can use the core components to guide decisions about transition program and intervention content. Confirmation of the impact of these core program components on youth outcomes awaits the conduct of rigorous randomized trials. Future research also needs to explicitly focus on the development of indicators to evaluate transition programs and interventions.

Clinician perspectives on the use of National Institute for Health and Care Excellence guidelines for the process of transition in Attention Deficit Hyperactivity Disorder

BACKGROUND

The UK National Institute for Health and Care Excellence (NICE) clinical guidelines recommends the following steps in the transition from child to adult services for young people with attention deficit hyperactivity disorder (ADHD): reassessment before and after transition, transition planning, formal meeting between services, and involvement from young person and carer, completed by age 18.

METHODS

A UK surveillance study asked clinicians to report young people on their caseloads with ADHD in need of transition to adult services in 2016 to support their continued access to medication need. Clinicians reported young people as they aged to within 6 months of the transition boundary, a prospective questionnaire prior to transition asked about intended transition and the use of local transition protocols. A retrospective questionnaire sent 9 months later established which steps recommended by NICE were followed during transition. Clinicians (38) working in child or adult services were interviewed about their experiences of transition and the use of NICE guidelines during transition and were analysed using a framework approach.

RESULTS

Information was shared between services in 85% of the 315 identified transition cases. A joint meeting was planned in 16% of cases; joint working before transfer occurred in 10% of cases. Clinicians were aware of NICE guidelines; they had mixed views on whether (local) guidelines or protocols were helpful. The main reason for not following guidelines was workload and resources: "NICE recommends stuff that is miles above what we will ever be able to provide".

CONCLUSIONS

Clinicians involved in the transition process of young people with ADHD judged NICE guidelines to be unrealistic given the current limited resources and service organization. More open dialogue is needed for recommendations on service models to bridge the gap between guideline recommendations and what is viewed as feasible and how implementation of guidance is funded, monitored, and prioritized. This may lead to valuable changes in the consultation process, for example, consideration of a layered (gold, standard, and minimal) system for some NICE guidelines.

Predictors of Behavioral Health Service Utilization in a Medicaid Enrolled Sample of Emerging Adults

Emerging adults (EA), individuals between the ages of 15-26, face many challenges in their transition to a new developmental stage, especially those with behavioral health concerns who do not receive the supports they need. Many EA drop out of services at 18, which is likely due in part to the need to transition to the adult service system and the lack of available transition support services in child/adolescent service systems. Though this is a clear disparity, research on EA service utilization, especially those enrolled in Medicaid and with co-occurring conditions, is rare. This paper begins to address this gap by examining variables at age 17 that predict the service utilization of continuously Medicaid enrolled EA at age 18. Data came from an administrative dataset. The sample had 4,548 EA and 53% were female, 50% identified with a minority group, and 19% were child-welfare involved. Exploratory logistic regression analyses were used. Minority EA had lower odds of utilizing services at age 18. EA involved with child welfare had greater odds of utilizing services at age 18. EA with at least one Substance Use Disorder (SUD) and at least one mental health disorder at 17 had a higher likelihood of service utilization at 18, the opposite was true for EA with only SUDs. These findings identified predictors of service utilization for an understudied sample-EA enrolled in Medicaid. Results provided preliminary evidence that EA with SUD diagnoses access behavioral health services differently than those without a SUD diagnosis, and that it is fruitful to examine subgroups of EA when seeking to understand their service utilization patterns. Identifying predictors of service utilization during the transition period from the child to the adult system can help inform systems interventions to retain EA in services.

In transition with ADHD: the role of information, in facilitating or impeding young people's transition into adult services

BACKGROUND

Many national and regional clinical guidelines emphasise the need for good communication of information to young people and their parent/carers about what to expect during transition into adult services. Recent research indicates only a minority of young people in need of transition for Attention Deficit Hyperactivity Disorder (ADHD) experience continuity of care into adulthood, with additional concerns about quality of transition. This qualitative study explored the role that information plays in experiences of transition from the perspectives of parent/carers and young people.

METHODS

Participants were recruited from 10 National Health Service Trusts, located across England, with varying service configurations. Ninety two qualitative interviews were conducted: 64 with young people with ADHD at different stages relative to transition, and 28 with parent/carers. Thematic analysis of data was completed using the Framework Method.

RESULTS

Interviewees reported a range of experiences; however reliance on parent/carers to gather and translate key information, and negative experiences associated with poor communication of information, were universal. Three themes emerged: Navigating information with help from parents; Information on ADHD into adulthood; Information about the transition process. The first revealed the essential role of parent in the translation and application of information, the other two explored distinct types of information necessary for a smooth transition. Interviewees made recommendations for clinical practice similar to UK (United Kingdom) National Institute for Health and Care Excellence (NICE) guidelines, with an additional emphasis on providing nuanced information on ADHD as a potentially long term condition. It was important to interviewees that General Practitioners had a basic understanding of adult ADHD and also had access to information about service provision.

CONCLUSIONS

Our findings illustrate that the availability and communication of information to young people and their parent/carers is an essential component of the transition process between child and adult ADHD services. How and when it is provided may support or impede transition. This study constitutes a substantial contribution to the evidence base, drawing on interviews from a range of participants across England and from Trusts offering different types of services.