Determinants of Transition From Child and Adolescent to Adult Mental Health Services: A Western Australian Pilot Study

Adaptation and validation of the On Your Own Feet - Transition Experiences Scale evaluating transitions to adult services among adolescent mental health service users in Europe

PURPOSE

Experiences of young people transitioning from Child and Adolescent Mental Health Services (CAMHS) to Adult Mental Health Services (AMHS) have mostly been investigated qualitatively. This study adapts and validates the On Your Own Feet - Transition Experiences Scale (OYOF-TES) in a sample of CAMHS users in Europe and describes young people's and parents' experiences with transition and end of care at CAMHS.

METHODS

The OYOF-TES was adapted to a mental health setting and translated. An End Of Care (OYOF-EOC) version (self- and parent-report) was developed. A total of 457 young people and 383 parents completed an OYOF-TES or OYOF-EOC. Psychometric properties and descriptives are presented.

RESULTS

The Cronbach's alphas of the OYOF-TES and OYOF-EOC parent/self-report ranged from 0.92 to 0.94. The two-factor structure was confirmed. The mean overall satisfaction reported by young people was 6.15 (0-10; SD=2.92) for transition and 7.14 (0-10; SD=2.37) for care ending. However, 26.7%-36.4% of young people were unsatisfied.

DISCUSSION

The OYOF-TES and OYOF-EOC can be used reliably in mental healthcare settings to capture young people's and parents' transition experiences. The majority of young people and parents was satisfied with the process of transition and care ending, yet a third of young people had negative experiences.

Social and Structural Drivers of Health and Transition to Adult Care

CONTEXT

Youth with chronic health conditions experience challenges during their transition to adult care. Those with marginalized identities likely experience further disparities in care as they navigate structural barriers throughout transition.

OBJECTIVES

This scoping review aims to identify the social and structural drivers of health (SSDOH) associated with outcomes for youth transitioning to adult care, particularly those who experience structural marginalization, including Black, Indigenous, and 2-spirit, lesbian, gay, bisexual, transgender, queer or questioning, and others youth.

DATA SOURCES

Medline, Embase, CINAHL, and PsycINFO were searched from earliest available date to May 2022.

STUDY SELECTION

Two reviewers screened titles and abstracts, followed by full-text. Disagreements were resolved by a third reviewer. Primary research studying the association between SSDOH and transition outcomes were included.

DATA EXTRACTION

SSDOH were subcategorized as social drivers, structural drivers, and demographic characteristics. Transition outcomes were classified into themes. Associations between SSDOH and outcomes were assessed according to their statistical significance and were categorized into significant (P < .05), nonsignificant (P > .05), and unclear significance.

RESULTS

101 studies were included, identifying 12 social drivers (childhood environment, income, education, employment, health literacy, insurance, geographic location, language, immigration, food security, psychosocial stressors, and stigma) and 5 demographic characteristics (race and ethnicity, gender, illness type, illness severity, and comorbidity). No structural drivers were studied. Gender was significantly associated with communication, quality of life, transfer satisfaction, transfer completion, and transfer timing, and race and ethnicity with appointment keeping and transfer completion.

LIMITATIONS

Studies were heterogeneous and a meta-analysis was not possible.

CONCLUSIONS

Gender and race and ethnicity are associated with inequities in transition outcomes. Understanding these associations is crucial in informing transition interventions and mitigating health inequities.

Improving the Scope of Child Mental Health Interventions in Our Modern World

Twenty years ago, an important systematic review showed that the empirical research evidence for interventions available for children and young people with mental health problems were rarely developed with their specific developmental needs in mind [...].

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.

Annual Research Review: A systematic review of mental health services for emerging adults - moulding a precipice into a smooth passage

BACKGROUND

The transition between child and adult services should aim to support young people into the next stage of their life in a way that optimises their function. Yet financial, organisational and procedural barriers to continuity of care often hamper smooth transition between child and adult services.

AIM AND METHOD

We reviewed studies of transition from child to adult mental health services, focusing on: (a) rates of referrals and referral acceptance; (b) barriers and facilitators of successful transition; (c) continuity of care during and post-transition and (d) service users' experience of transition. Studies were identified through systematic searches of electronic databases: PsycINFO, Medline, Embase and Child Development and Adolescent Studies.

FINDINGS

Forty-seven papers describing 43 unique studies met inclusion criteria. Service provision is influenced by previous history and funding processes, and the presence or absence of strong primary care, specialist centres of excellence and coordination between specialist and primary care. Provision varies between and within countries, particularly whether services are restricted to 'core' mental health or broader needs. Unsupportive organisational culture, fragmentation of resources, skills and knowledge base undermine the collaborative working essential to optimise transition. Stigma and young people's concerns about peers' evaluation often prompt disengagement and discontinuation of care during transition, leading to worsening of symptoms and later, to service re-entry. Qualitative studies reveal that young people and families find the transition process frustrating and difficult, mainly because of lack of advanced planning and inadequate preparation.

CONCLUSIONS

Despite increasing research interest over the last decade, transition remains 'poorly planned, executed and experienced'. Closer collaboration between child and adult services is needed to improve the quality of provision for this vulnerable group at this sensitive period of development.

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.

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.

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.

Transitioning from Adolescent to Adult Mental Health Services: An Integrative Literature Review

This article aims to present a review of the peer-reviewed, published literature related to the transition from adolescent mental health services to adult mental health services. Six databases (PubMED, Medline, PsycINFO, CINAHL, EMBASE, and Google Scholar) were searched for peer-reviewed, published literature on the transition from adolescent to adult mental health services. Articles on primary research were included in the review if they were published in English between 2000 and 2018, and if they were explicitly about alignment and/or transition between adolescent and adult mental health services. Fifty articles were included in the final review. The findings are discussed in two overarching streams of research from the literature: evaluations of transition arrangements, and the perspectives of various stakeholders (including consumers, carers, and health professionals). The results emphasise the problematic siloes of adolescent and adult mental health services. While there are still no randomised controlled trials on transition to assess transition pathways, our findings have implications to inform best practice in the sector. Given that transitioning to adult mental health services is seen as a point of vulnerability for young people, this review contributes to understandings about how services can offer better support during transition periods.

Outcomes of young people who reach the transition boundary of child and adolescent mental health services: a systematic review

When young people reach the upper age limit of child and adolescent mental health services (CAMHS), care should be transferred to an adult mental health service (AMHS) if they require ongoing support. However, many young people experience a significant disruption of their care during this transition, whilst others may fail to transition at all. Currently, there is no systematic appraisal of the international evidence regarding the outcomes of young people after transition. A systematic review was conducted which aimed to synthesise and review the existing research regarding outcomes after transition. We searched six databases from their inception until December 2017 for research relating to either the mental health or service use outcomes of young people after reaching their CAMHS age boundary. Results were synthesised narratively. The initial searches identified 18,287 papers, of which 213 were screened on full text. 13 papers were included in the review, representing 10 cohorts of young people who crossed the transition age boundary. No studies contained extractable data on mental health outcomes following transition, and therefore, this review focused only on service use outcomes. Results showed a quarter of young people transitioned to AMHS, with the other young people experiencing varied outcomes after leaving CAMHS and multiple transitions during this time. This review provides evidence for the varying service use outcomes of young people after reaching the upper age limit of CAMHS. However, longitudinal research into long-term outcomes is lacking, in addition to research regarding the mental health and functioning outcomes of young people following transition.Protocol registration The protocol for this systematic review has been registered with PROSPERO, ID number CRD42018085916.