The transition process from child to adult mental health services differs between countries. For further information, please consult your local guidelines.
How successful is the transition from child to adult mental health services?
Continuity of care into adulthood for adolescents with attention-deficit hyperactivity disorder (ADHD), or hyperkinetic disorder (HKD), occurs less frequently than persistence rates of care would predict, leading to some individuals being ‘lost in transition’.1 A systematic review of experiences of healthcare transitions in young people with ADHD in Hong Kong, Italy and the UK found the following emerging themes: difficulties in transitioning; limitations of adult mental health services; hurdles that had to be negotiated; inadequate care; and the impact of transition difficulties.2 Poor adherence to treatment may also lead some individuals to become lost from the system. Many factors influence adherence in adolescents, including the individual’s perception of effectiveness and tolerability, and parental influence.3 There is a need for a more structured approach to transition protocols that are adopted by healthcare professionals in both child and adult services.4
‘Lost in transition’ in adulthood
One audit of the transition policies and procedures from child to adult mental health services, published in 2010, found that <5% of individuals who made a transition experienced optimal transition. In this study, optimal transition was defined as ‘adequate transition planning, good information transfer across teams, joint working between teams and continuity of care following transition’. Individuals 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. For the individuals who did transition, most service users stayed engaged with adult mental health services and reported improvement in their mental health.5
In a separate surveillance study conducted between November 2015 and August 2017 in the UK, the annual number of young people with ADHD aged 17–19 years with an ongoing need for medication was between 170 and 599 per 100,000 people. Of the 315 individuals who were eligible for transition to adult mental health services in this study, 64% were accepted; however, only 22% attended their first appointment for adult mental health services. Only a small proportion of young people with ADHD experienced optimal transition to adult mental health services, few of which provided the full range of treatments recommended by NICE.6
One audit of transition policies found that <5% of individuals experienced optimal transition from child to adult mental health services.5
How can individuals with ADHD be transitioned from child to adult mental health services successfully?
The NICE guidelines 2018 recommend that a young person with ADHD receiving care and treatment from child and adolescent mental health services should be reassessed at school-leaving age to determine the need for treatment continuation in adulthood. It is recommended that arrangements are made to enable smooth transition to adult mental health services. The NICE guidelines 2018 highlight that the precise timing of arrangements may vary locally but are recommended to be completed before the young person is aged 18 years.7 Furthermore, the CADDRA guidelines 2020 suggest that psychosocial interventions can play a particularly important role during key life transitions, including the transition from adolescence to adulthood.8
The MILESTONE (ManagIng the Link and strEngthening tranSiTiON from child and adult mEntal health care) study aimed to characterise transitions of young people from Child and Adolescent Mental Health Services (CAMHS) to Adult Mental Health Services (AMHS) across Europe. In most countries (20/28 [71%]), there was an official national CAMHS policy covering young people until their transition age. In two (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). This flexibility allowed young people to remain in services beyond the 18-year age limit if the treating clinician considered this extension appropriate. Across 27 countries, the CAMHS policies also included key components such as regulations on the types of healthcare provided and on the competency of care providers (17 [63%]), guidelines regarding access to services (59%), and written standards of service provision (13 [48%]).9
Optimising transition: Bridging the gap in clinical practice
To successfully transition individuals 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 (Figure 1).10-13
Figure 1: Considerations for successful transitioning between child and adult mental health services. Figure developed from multiple sources.5,10-13
How can we improve transition?
- Buitelaar JK. Optimising treatment strategies for ADHD in adolescence to minimise ‘lost in transition’ to adulthood. Epidemiol Psychiatr Sci 2017; 26: 448-452.
- Price A, Janssens A, Woodley AL, et al. Review: Experiences of healthcare transitions for young people with attention deficit hyperactivity disorder: a systematic review of qualitative research. Child Adolesc Ment Health 2019; 24: 113-122.
- Charach A, Fernandez R. Enhancing ADHD medication adherence: challenges and opportunities. Curr Psychiatry Rep 2013; 15: 371.
- 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.
- 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.
- Janssens A, Eke H, Price A, et al. The transition from children’s services to adult services for young people with attention deficit hyperactivity disorder: the CATCh-uS mixed-methods study. Health Serv Deliv Res 2020; 8(42).
- NICE guideline 2018. Attention deficit hyperactivity disorder: diagnosis and management. Available at: https://www.nice.org.uk/guidance/ng87. Accessed January 2021.
- Canadian ADHD Resource Alliance (CADDRA). Canadian ADHD Practice Guidelines. Edition 4.1. Toronto, ON: CADDRA, 2020.
- 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.
- Patel V, Flisher AJ, Hetrick S, et al. Mental health of young people: a global public-health challenge. Lancet 2007; 369: 1302-1313.
- 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.
- 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.
- 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 January 2021.