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The journey through adolescence into adulthood is a time of significant physical, psychological and social change. During this period, adolescents may become lost in the system between child and adult mental health services and may have nobody to ensure attendance.1

Transition from child to adult mental health care in Europe

MILESTONE study

The aim of the MILESTONE (ManagIng the Link and strEngthening tranSiTiON from child and adult mEntal health care) study was to improve transitions of young people from Child and Adolescent Mental Health Services (CAMHS) to Adult Mental Health Services (AMHS) across Europe.2 Data collected between 1 October 2014 and 21 March 2015 showed that the number of public CAMHS varied considerably across countries, from two each in Malta and Luxembourg to 939 in the UK (Figure).2

Figure: Number of CAMHS per 100,000 young people in EU countries. Reproduced with kind permission from Signorini G et al. Lancet Psychiatry 2017; 4: 715-724.2

Number of CAMHS per 100,000 young people in EU countries

MILESTONE study: CAMHS polices across the EU

In most countries (20/28 [71%]), there was an official national CAMHS policy covering young people until their transition age. In 2 (7%) countries, this policy had been adapted to extend its coverage to a few years after the transition age (to 23 years in Finland and 21 years in Germany).2 This flexibility allows young patients to remain in services for a few years beyond the 18-year limit if the treating clinician considers this extension appropriate.2

The policies also included the following key components:

  • Regulations on the types of healthcare provided and on the competency of care providers (17 [63%] of 27 countries)2
  • Guidelines regarding access to services (16 [59%] of 27 countries)2
  • Written standards of service provision (13 [48%] of 27 countries)2
  • Other matters, e.g. rights regarding consent and privacy (2 [7%] of 27 countries).2

Various sectors were also reported to be involved in the development of policies about CAMHS, including:

  • Mental health (18 [64%] countries)2
  • Primary care (15 [54%] countries)2
  • Child protection (14 [50%] countries)2
  • Health and social welfare (10 [36%] countries)2
  • Human rights (8 [29%] countries)2
  • Other social services (2 [7%] countries).2

The National Institute of Health and Care Excellence (NICE) published guidelines in 2016 for young people using health and social care services transitioning from child to adult services (Figure). The guidelines aim to help young people and their parents/carers have a better experience of transitioning between services.

Figure: NICE guidelines (2016) on transition to UK adult services – a summary of guidance. Note that these are examples and not an exhaustive list.3

NICE guidelines (2016) on transition to UK adult services – a summary of guidance

TRACK study

An audit of the transition policies and procedures within six mental health trusts in London and the West Midlands (three trusts in each region) aimed to evaluate the process of transition through a case-note survey; all actual and potential referrals from CAMHS to AMHS in the preceding year were identified, and their journey and outcomes ‘tracked’ to determine the predictors of successful transition.4 The study also aimed to explore the views of service users, carers and mental health professionals on the transition process.4

In total, 154 patients crossed the transition boundary in 1 year, with 90 actual referrals (i.e. patients made a transition to AMHS) and 64 potential referrals (i.e. patients were either not referred to AMHS or not accepted by AMHS). Patients with a history of severe mental illness, those on medication or those who had been admitted were more likely to make a transition than those with neurodevelopmental disorders, emotional/neurotic disorders and emerging personality disorder.4

The audit found that <5% of patients who made a transition experienced optimal transition, which was defined as ‘adequate transition planning, good information transfer across teams, joint working between teams and continuity of care following transition’.4

For the patients who did transition, most service users stayed engaged with AMHS and reported improvement in their mental health.4

Figure: Recommendations from the TRACK study. Figure developed from information from Singh SP et al. Br J Psychiatry 2010; 197: 305-312. Note that these are examples and not an exhaustive list; see reference for full list of recommendations.4

Recommendations from the TRACK study

‘Lost in transition’ in adulthood

Continuity of care into adulthood for patients with ADHD occurs less frequently than persistence rates of the condition would predict, leading to some patients being ‘lost in transition’.5

Despite the government and the NICE guidelines highlighting the importance of the transition from child to adult mental health services, there is a clear need for a more structured approach to transition protocols that are adopted by healthcare professionals in both child and adult services.6

‘Lost in transition’ in adulthood



Transitional care for adolescents with ADHD

Results from the Irish Transition of Care from Child and Adolescent Mental Health Services to Adult Mental Health Services (iTRACK) study showed that in a sample of 20 adolescents with ADHD, none were successfully transitioned to public adult mental health care services at the transition boundary, and eight disengaged from services altogether (Figure).7

Figure: Results from the TRACK study (n=20). Figure reproduced with kind permission from Tatlow-Golden M et al. Early Interv Psychiatry 2018; 12: 505-512. 7

Results from the TRACK study (n=20)

AMHS, Adult Mental Health Services; CAMHS, Child and Adolescent Mental Health Services

Optimising transition: Bridging the gap in clinical practice




A prospective longitudinal study of 91 young people (aged 14–24 years) with ADHD, recruited from the UK, found that only 9% had transitioned to adult services, with the majority reporting unmet needs in healthcare transition. The odds of reported contact with clinical services decreased by 35% as patients aged, despite 62% of patients meeting the diagnostic criteria for ADHD at baseline and presenting with a range of ADHD-related symptoms, psychiatric comorbidities and significant caregiver burden. These data suggest that service models should address the needs of patients with ADHD who are no longer children, and improve the planning, co-ordination and continuity of healthcare during the transition to adult services.8­­

Poor adherence to medication may also lead patients to become lost from the system. Many factors influence medication adherence in adolescents, including the patient’s perception of effectiveness and tolerability, and parental influence.9

A 2017 German study showed that medication rates in adolescents with ADHD (n=5593) fell from 51.8% at age 15 years to 6.6% at age 21 years (Figure).10 In addition, a longitudinal study of patients aged 15 years with ADHD (n=44) reported that all participating patients had discontinued ADHD medication by the age of 21 years.11

Figure: Percentage of patients in a transition cohort (n=5593; 15 years old) with a diagnosis of ADHD or receiving ADHD medication over time from 2008 to 2014. Figure reproduced with kind permission from Bachmann CJ et al. Dtsch Arztebl Int 2017; 114: 141-148.10

Percentage of patients in a transition cohort (n=5593; 15 years old) with a diagnosis of ADHD or receiving ADHD medication over time from 2008 to 2014

Data based on nationwide routine data of the Allgemeine Ortskrankenkassen statutory health insurnace fund to determine the frequency of the ADHD diagnoses and presciptions of medication for ADHD.

Examples of issues to consider for a successful transition of care

To successfully transition patients from child to adult mental health services, it is important to consider the timing of transitioning, the differences between practices and culture, and the fact that differences in care structure may affect collaboration between agencies.12-15

Figure: Examples of issues to consider for successful transitioning between CAMHS and AMHS. Figure developed from multiple sources.12-15

Examples of issues to consider for successful transitioning between CAMHS and AMHS

AMHS, Adult Mental Health Services; CAMHS, Child and Adolescent Mental Health Services

How can we improve transition?



  1. Lamb C, Hall D, Kelvin R, et al. Working at the CAMHS/adult interface: good practice guidance for the provision of psychiatric services to adolescents/young adults. A joint paper from the Interfaculty working group of the Child and Adolescent Faculty and the General and Community Faculty of the Royal College of Psychiatrists. 2008.
  2. Signorini G, Singh SP, Boricevic-Marsanic V, et al. Architecture and functioning of child and adolescent mental health services: a 28-country survey in Europe. Lancet Psychiatry 2017; 4: 715-724.
  3. National Institute for Health and Care Excellence. Transition from children’s to adults’ services for young people using health or social care services. 2017. Available at: www.nice.org.uk/guidance/ng43. Accessed February 2019.
  4. Singh SP, Paul M, Ford T, et al. Process, outcome and experience of transition from child to adult mental healthcare: multiperspective study. Br J Psychiatry 2010; 197: 305-312.
  5. Buitelaar JK. Optimising treatment strategies for ADHD in adolescence to minimise ‘lost in transition’ to adulthood. Epidemiol Psychiatr Sci 2017; 26: 448-452.
  6. Hall CL, Newell K, Taylor J, et al. ‘Mind the gap’–mapping services for young people with ADHD transitioning from child to adult mental health services. BMC Psychiatry 2013; 13: 186.
  7. Tatlow-Golden M, Gavin B, McNamara N, et al. Transitioning from child and adolescent mental health services with attention-deficit hyperactivity disorder in Ireland: case note review. Early Interv Psychiatry 2017; 12: 505-512.
  8. Eklund H, Cadman T, Findon J, et al. Clinical service use as people with attention deficit hyperactivity disorder transition into adolescence and adulthood: a prospective longitudinal study. BMC Health Serv Res 2016; 16: 248.
  9. Charach A, Fernandez R. Enhancing ADHD medication adherence: challenges and opportunities. Curr Psychiatry Rep 2013; 15: 371.
  10. Bachmann CJ, Philipsen A, Hoffmann F. ADHD in Germany: trends in diagnosis and pharmacotherapy. Dtsch Arztebl Int 2017; 114: 141-148.
  11. McCarthy S, Asherson P, Coghill D, et al. Attention-deficit hyperactivity disorder: treatment discontinuation in adolescents and young adults. Br J Psychiatry 2009; 194: 273-277.
  12. Patel V, Flisher AJ, Hetrick S, et al. Mental health of young people: a global public-health challenge. Lancet 2007; 369: 1302-1313.
  13. Singh SP, Evans N, Sireling L, et al. Mind the gap: the interface between child and adult mental health services. Psychiatric Bulletin 2005; 29: 292-294.
  14. Swift KD, Hall CL, Marimuttu V, et al. Transition to adult mental health services for young people with attention deficit/hyperactivity disorder (ADHD): a qualitative analysis of their experiences. BMC Psychiatry 2013; 13: 74.
  15. Gillam T, Crofts M, Fadden G, et al. The Interfaces Project Report – Exploring the links between mental health services for children, adults and families. 2003. Available at: https://www.meridenfamilyprogramme.com/download/family-work/whole-family-approaches/Interfaces_Project_Report.doc. Accessed February 2019.
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