Transitioning from child and adolescent mental health services with attention-deficit hyperactivity disorder in Ireland: Case note review

[Neurodevelopmental Psychiatry Consultation: A National Level Analysis]

INTRODUCTION

Neurodevelopmental disorders are characterized by delay or variation in the acquisition of abilities or skills in several domains of development: motor, social, language, and cognitive. These disorders can manifest from childhood to adulthood, and therefore continuity of care is essential throughout these various developmental periods. However, several studies show that there is limited access to adult health care in this clinical domain.

METHODS

A cross-sectional observational study was carried out by distributing an anonymous survey among psychiatry physicians, at a national level, in the period between October 6 and December 6, 2020.

RESULTS

Data was collected from 83 psychiatry physicians (43 residents and 40 specialists). At the national level, only 16.9% of psychiatric departments had a subspecialized neurodevelopment clinic. Physicians reported that they observed few patients with neurodevelopment disorders: 72.3% observed one or none per week. When there was a neurodevelopmental disorders clinic in the psychiatry department, 64.3% of physicians reported that this clinic did not include a multidisciplinary team. The transition of these patients from the pediatric/child and adolescent psychiatry department to the psychiatric department occurred through regular intrahospital transfer in 51.8% of cases, but it occurred through a specific protocol or with a transitional medical appointment in only 15.7% of cases. Finally, 88% of psychiatry physicians considered the existence of a neurodevelopmental disorders clinic in adults to be pertinent and reported not having specialized training in the field of neurodevelopment.

CONCLUSION

This study made it possible to identify some difficulties and barriers regarding adequate access for patients with neurodevelopmental disorders throughout the various developmental stages, from childhood to adulthood: lack of training in this clinical field, need of better communication between departments, lack of specific protocols, shortage of multidisciplinary teams, and asymmetry in the distribution of differentiated care.

Parenting roles for young people with attention-deficit/hyperactivity disorder transitioning to adult services

AIM

To inform transitions from child to adult health services, we explored the work and roles parents take in the care of young people with attention-deficit/hyperactivity disorder (ADHD) aged 14 to 25 years old.

METHOD

Using framework thematic analysis, we analysed data collected from 28 semi-structured interviews with parents of young people with ADHD to generate a typology and triangulated it against findings from 64 interviews with young people with ADHD. The interviews were carried out as part of a three-strand, interactive mixed-method study.

RESULTS

An entourage typology of three parent roles was identified. Parents moved between 'manager' and 'roadie' roles as their child gradually matured. A 'superfan' role was identified which supported young people's positive self-image but may impede withdrawal from the 'manager' role. Continued parental involvement into adulthood reflected a need to maintain the balance of resources required to maintain quality of life for the whole family.

INTERPRETATION

This is the first study to explore parental roles in the health care of young people with ADHD. Parents will vary in their capacity to fulfil the identified roles and step back their care as their children reach adulthood. The findings can inform intervention development to support families and transition between services.

WHAT THIS PAPER ADDS

Parents move from a 'manager' to 'roadie' role as young people mature. A 'superfan' role supports positive self-image and directed health care work. Continued involvement reflects parental responsibility to juggle wider family needs and resources. Parents differ in capacity to fulfil and move between these roles.

Transition care for adolescents and young adults with attention-deficit hyperactivity disorder (ADHD): A descriptive summary of qualitative evidence

The review presents a summary of available evidence about transition care of ADHD patients from all service users' perspectives. Common barriers, and suggestions for improvement ADHD of transition care, were extrapolated from qualitative research, including case notes studies, and were exposed. A comprehensive search of the PubMed, Embase, PsychInfo and Web of Science databases for articles published up to October 2021 was conducted to summarize recent evidence on the experiences of all stakeholders involved in the transition process. Reviews, other chronic conditions and different meaning of transition were excluded. Authors extracted data and assessed study quality independently. Findings were discussed taking into consideration barriers and suggestions from all service users' perspectives. Findings from 23 studies with different context and methods were collected and summarized. Most of the studies were conducted in UK, using interviews and questionnaires, and addressed to the physicians. The lack of information about ADHD as a condition and about transition process were the barriers most reported, while joint working and sharing transition protocols were the suggestions pointed out by all stakeholders. Despite different perspectives, all stakeholders exposed similar needs. The review reveals an evident need for defining and evaluating the effectiveness of transition programmes from child to adult ADHD services.

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.

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.

Transition between child and adult services for young people with attention-deficit hyperactivity disorder (ADHD): findings from a British national surveillance study

BACKGROUND

Optimal transition from child to adult services involves continuity, joint care, planning meetings and information transfer; commissioners and service providers therefore need data on how many people require that service. Although attention-deficit hyperactivity disorder (ADHD) frequently persists into adulthood, evidence is limited on these transitions.

AIMS

To estimate the national incidence of young people taking medication for ADHD that require and complete transition, and to describe the proportion that experienced optimal transition.

METHOD

Surveillance over 12 months using the British Paediatric Surveillance Unit and Child and Adolescent Psychiatry Surveillance System, including baseline notification and follow-up questionnaires.

RESULTS

Questionnaire response was 79% at baseline and 82% at follow-up. For those aged 17-19, incident rate (range adjusted for non-response) of transition need was 202-511 per 100 000 people aged 17-19 per year, with successful transition of 38-96 per 100 000 people aged 17-19 per year. Eligible young people with ADHD were mostly male (77%) with a comorbid condition (62%). Half were referred to specialist adult ADHD and 25% to general adult mental health services; 64% had referral accepted but only 22% attended a first appointment. Only 6% met optimal transition criteria.

CONCLUSIONS

As inclusion criteria required participants to be on medication, these estimates represent the lower limit of the transition need. Two critical points were apparent: referral acceptance and first appointment attendance. The low rate of successful transition and limited guideline adherence indicates significant need for commissioners and service providers to improve service transition experiences.

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.

Experience of transfer from child to adult mental health services of young people with autism spectrum disorder

BACKGROUND

Transition from child-centred to adult mental health services has been reported as challenging for young people. It can be especially difficult for young people with autism spectrum disorder (ASD) as they manage the challenges of adolescence and navigate leaving child and adolescent mental health services (CAMHS).

AIMS

This study examines the predictors of transfer to adult mental health services, and using a qualitative analysis, explores the young people's experiences of transition.

METHOD

A UK sample of 118 young people aged 14-21 years, with ASD and additional mental health problems, recruited from four National Health Service trusts were followed up every 12 months over 3 years, as they were discharged from CAMHS. Measures of mental health and rich additional contextual information (clinical, family, social, educational) were used to capture their experiences. Regression and framework analyses were used.

RESULTS

Regression analysis showed having an attention-deficit hyperactivity disorder diagnosis and taking medication were predictors of transfer from child to adult mental health services. Several features of young people's transition experience were found to be associated with positive outcomes and ongoing problems, including family factors, education transitions and levels of engagement with services.

CONCLUSIONS

The findings show the importance of monitoring and identifying those young people that might be particularly at risk of negative outcomes and crisis presentations. Although some young people were able to successfully manage their mental health following discharge from CAMHS, others reported levels of unmet need and negative experiences of transition.

Transitional care for young adults with ADHD: transforming potential upheaval into smooth progression

Increasing numbers of young adults need continued support for their attention deficit hyperactivity disorder (ADHD) beyond the age-boundary for children's services. The sparse literature on transition in general suggests patchy provision and huge gaps in transitional care, but also that young people with ADHD and other neurodevelopmental disorders fair particularly badly. Transition in health care coincides with many other important life-transitions while the difficulties associated with ADHD may make these challenges particularly hard to cope with. Parents or other advocates therefore often need to be involved, which can present problems in adult mental health services given that they tend to be less family oriented than children's services. Importantly, young people need help negotiating the transition from passive recipient of care to active self-management, and in building relationships with the adult team.In addition to patchy provision of adult ADHD services, transition is currently hampered by poor understanding of ADHD as a long term condition and uncertain knowledge of what services are available among young people and parents as well as the clinicians working with them. Guidelines recommend, and more importantly young people want, access to psycho-social interventions as well as medication. However, available evidence suggests poor quality transitional care and adult services that are highly focused on medication.Adult ADHD services need to undergo similar development to that experienced by Child and Adolescent Mental Health Services and community paediatrics over the last few decades. While we debate the relative merits of dedicated or specialist v. generic adult mental health services, for young adults with ADHD the training, experience and availability of professionals are more important than their qualifications or setting.

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.

How to measure the need for transition to adult services among young people with Attention Deficit Hyperactivity Disorder (ADHD): a comparison of surveillance versus case note review methods

BACKGROUND

Health services have not provided adequate support for young people with long term health conditions to transfer from child to adult services. National Institute of Health and Care (NICE) guidance on transition has been issued to address these gaps. However, data are often sparse about the number of young adults who might need to transition. Using Attention Deficit Hyperactivity Disorder (ADHD) as an exemplar, this study used an existing surveillance system and a case note review to capture the incidence of the transition process, and compared and contrasted the findings.

METHODS

The Child and Adolescent Psychiatry Surveillance System (CAPSS) was used to estimate the incident transition of young people with Attention Deficit Hyperactivity Disorder (ADHD) from child to adult services. This involves consultant child and adolescent psychiatrists from the United Kingdom (UK) and Republic of Ireland (ROI) reporting relevant young people as they are seen in clinics. In parallel, a case note review was conducted using the Maudsley Biomedical Research Centre (BRC) Clinical Records Interactive Search (CRIS). The study period ran for twelve months with a nine month follow up to see how the transition proceeded.

RESULTS

CRIS identified 76 cases in the study period, compared to 18 identified using surveillance via CAPSS. Methodological issues were experienced using both methods. Surveillance issues; eligibility criteria confusion, reporting errors, incomplete questionnaires, difficulties contacting clinicians, and surveillance systems do not cover non-doctors and psychiatrists who are not consultants. Case note review issues using CRIS included the need for researchers to interpret clinical notes, the availability and completeness of data in the notes, and data limited to the catchment of one particular mental health trust.

CONCLUSIONS

Both methods demonstrate strengths and weaknesses; the combination of both methods in the absence of strong routinely collected data, allowed a more robust estimate of the level of need for service planning and commissioning.

Review: Transition from children's to adult services: a review of guidelines and protocols for young people with attention deficit hyperactivity disorder in England

BACKGROUND

In recent years, the difficulty for young people with mental health issues who require a transition to adult services has been highlighted by several studies. In March 2018 the National Institute of Health and Care Excellence (NICE) produced detailed guidelines for the diagnosis and management of attention deficit hyperactivity disorder (ADHD), updated from previous versions in 2008 and 2016, which included general recommendations for transition to an adult service. Yet, there is limited research on transition specifically for those with ADHD. This review aims to systematically identify, review and compare guidelines, specifically focussed on transition for young adults with ADHD within England.

METHODS

Following the general principles for systematic reviewing as published by the University of York, 10 electronic databases were searched. Further documents were identified through searches of grey literature and additional sources.

RESULTS

Sixteen documents were included. Results indicate very limited publically accessible guidelines in England for transition of young people with ADHD. Nearly all identified documents based their recommendations for transition on the existing NICE guidelines. Neurodevelopmental conditions such as ADHD are often encompassed within one overarching health policy rather than an individual policy for each condition.

CONCLUSIONS

Guidelines should be available and accessible to the public in order to inform those experiencing transition; adjusting the guidelines to local service context could also be beneficial and would adhere to the NICE recommendations. Further review could examine transition guideline policies for mental health in general to help identify and improve current practice.

Attaining the age threshold for adolescent mental health services: factors associated with transition of care in the independent sector in Ireland

OBJECTIVES

The transition from adolescent to adult mental health services (AMHS) is associated with disengagement, poor continuity of care and patient dissatisfaction. The aim of this retrospective and descriptive study was to describe the 'care pathways' in an independent mental health service when adolescents reach age 18 and to investigate the level of engagement of those who transitioned to independent AMHS.

METHODS

This is a retrospective, naturalistic and descriptive study in design. All patients discharged from the St Patrick's Adolescent Mental Health Service aged 17 years and 6 months and older, during a 3-year period between January 2014 and December 2016, were included. Electronic records were used to collect socio-demographic and clinical details and to determine engagement rates in adolescents who transferred to independent adult services.

RESULTS

A total of 180 patients aged over 17 years and 6 months were discharged from the adolescent service. Of these, 45.6% were discharged to their GP, 28.9% to public mental health services and 25.6% to independent mental health services. The majority who transitioned to independent AMHS went to a Young Adult Service, which had high engagement rates at 3 and 12 months post-transition.

CONCLUSIONS

In this independent mental health service, less than half of adolescents who reach the transition age are referred onto AMHS. Engagement rates were found to be high among those referred on to a specialised young adult service.

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.

The interface between child/adolescent and adult mental health services: results from a European 28-country survey

Transition-related discontinuity of care is a major socioeconomic and societal challenge for the EU. The current service configuration, with distinct Child and Adolescent Mental Health (CAMHS) and Adult Mental Health Services (AMHS), is considered a weak link where the care pathway needs to be most robust. Our aim was to delineate transitional policies and care across Europe and to highlight current gaps in care provision at the service interface. An online mapping survey was conducted across all 28 European Countries using a bespoke instrument: The Standardized Assessment Tool for Mental Health Transition (SATMEHT). The survey was directed at expert(s) in each of the 28 EU countries. The response rate was 100%. Country experts commonly (12/28) reported that between 25 and 49% of CAMHS service users will need transitioning to AMHS. Estimates of the percentage of AMHS users aged under 30 years who had has previous contact with CAMHS were most commonly in the region 20-30% (33% on average).Written policies for managing the interface were available in only four countries and half (14/28) indicated that no transition support services were available. This is the first survey of CAMHS transitional policies and care carried out at a European level. Policymaking on transitional care clearly needs special attention and further elaboration. The Milestone Study on transition should provide much needed data on transition processes and outcomes that could form the basis for improving policy and practice in transitional care.