It is reported that 15% of childhood ADHD cases continue to meet full diagnostic criteria for ADHD in their twenties, with a further 50% continuing to experience impairment in adulthood due to subclinical symptoms (Faraone SV, et al. 2006). In childhood, ADHD is a common reason for attendance at Child and Adolescent Mental Health Services (CAMHS) or community paediatric services. However, the literature suggests that the transition between child and adult mental health services poses challenges in terms of limited provision of services and poor planning, and it is reported that adolescents with neurodevelopmental disorders such as ADHD are particularly likely to not complete the transition to adult services. Adolescence can be a challenging transitional period of life, involving developmental and situational changes such as increased independence from parents, leaving school or starting work. The age boundary for transition between child and adult services coincides with these additional challenges, and for adolescents with ADHD, impairments associated with their disorder may make these changes more difficult to cope with. Reports suggest that continuation of ADHD medication from adolescence into early adulthood is associated with reduced levels of suicidal behaviour, substance misuse, depression and criminal convictions. Therefore, optimal transition of care for young people with ADHD and ongoing clinical need is important.
Barriers to optimal transition
Common barriers to successful transition between CAMHS and adult services include changing relationships, difficulties in accessing adult practitioners and gaining funding, negative beliefs about adult care, a lack of knowledge about the transition process and a lack of self-management skills. The authors suggested that preparing adolescents with ADHD for transition may represent an important target for improving the process, and emphasised that preparation should begin early in adolescence, to allow time for development of self-management skills.
Additional ADHD-specific barriers to transition include a lack of service provision, a lack of knowledge amongst patients about service provision and poor understanding or scepticism about the persistence of ADHD into adulthood. The CATCH-uS surveillance study assessed the impact of these barriers through semi-structured interviews with three groups of young people (those attending CAMHS before transition, those who had transitioned to adult services and those who dropped out of CAMHS and re-entered adult services after ≥1 year), their parents, and clinicians from both child and adult services. The study found that only one-fifth of adolescents with ADHD who needed and wanted to continue treatment for ADHD successfully transitioned between services, and only 6% experienced optimal transition at follow-up. The study identified ‘initial referral’ (75% of adolescents with ADHD were referred to adult services; 63% accepted) and ‘continuity of care after referral’ (22% of those referred attended their first appointment in adult services) as weak points in the transitional process. The authors of this report suggested that these steps may represent important targets for service improvement.
Potential for disengagement from services
A lack of transitional service provision could lead to premature disengagement from mental health services or discharge to primary care despite an ongoing clinical need. Another commonly cited reason for disengagement identified by CATCH-uS was a perception amongst adolescents and their parents that their ADHD medication was predominantly related to coping with academic demands. Data from UK primary care suggest that, despite national ADHD guidelines recommending continuation of ADHD treatment for adults, only 18% of adolescents prescribed ADHD medications continue to receive prescriptions after the age of 18 years. However, among those who stop receiving their prescription, 7.6% resume their medication after the age of 20, following referral to adult mental health services. The authors suggested that this indicates a need to educate young people on the impact ADHD can have across their lifespan, and to increase their awareness of strategies that they can use to manage their ADHD. Correspondingly, current ADHD guidelines suggest reassessment at the point of transition, which may prompt these important discussions with the adolescent and facilitate optimal transition.
What should adult services provide?
The authors suggested that there is a focus on pharmacological medication rather than a multimodal approach in the treatment of adult ADHD, and highlighted that although many individuals with ADHD may welcome psychological support, practitioners have reported that they lack the time or resources to offer this treatment option. Cognitive behavioural techniques and mindfulness-based approaches may aid the improvement of self-awareness and self-management in ADHD, and such techniques could be offered via individually tailored smartphone apps or games, which may encourage engagement in adolescents and young adults with ADHD. The authors emphasised that adult services should negotiate carefully the transfer of management of care and decision-making from the parent/caregiver to the young person with ADHD, noting that the needs and opinions of the patient and their carers may not always align. The authors opined that this shift in responsibility should occur gradually over time, and that the effective management of this process by adult services may represent a therapeutic target.
Structure and organisation of transition in care
Provision of optimal transition between CAMHS and adult services is influenced by structural issues including the presence/absence of strong primary care, availability of specialist centres, quality of collaboration between specialist and primary care, and whether both adult and paediatric care is available in each of these settings. Additionally, child/adolescent and adult services are rarely financed and administered within the same organisation, and specialisation of healthcare professionals in paediatric- or adult-centred healthcare often occurs at an early stage in their training. This may result in cultural or knowledge gaps between child and adult services, in addition to fragmentation of skills, organisation and resource, which may undermine effective collaboration between services, thereby preventing optimal transition.
Debate continues amongst stakeholders as to whether effective care for adult ADHD can be adequately provided by generic adult mental health services, compared with specialist services. However, there is a paucity of evidence to support any particular model of care for young people with ADHD. The authors suggested that a combined approach may be beneficial, with provision of training, consultation and direct care for patients with complex ADHD-related impairments by highly specialised services complementing more widespread support from generic adult mental health services. However, robust evaluation of the effectiveness of such a model is required.
The authors concluded that adult ADHD services require similar development and improvement to that observed in CAMHS over recent years. They highlighted that, although clinical guidelines recommend that transitional care, reassessment, drug monitoring and psychoeducation should be available for adults with ADHD, service provision remains highly variable, and successful transition of individuals with ADHD between child and adult services is rare. The authors recommended that the number of young people with ADHD requiring transition between services is likely to increase as the number of children prescribed medication for ADHD increases, and that service providers should plan accordingly. They suggested that for young adults with ADHD, access to professionals with knowledge, understanding and experience of the disorder is the most important factor to aid successful continuity of care into adulthood.
Faraone SV, Biederman J, Mick E. The age-dependent decline of attention deficit hyperactivity disorder: a meta-analysis of follow-up studies. Psychol Med 2006; 36: 159-165.
Ford T. Transitional care for young adults with ADHD: transforming potential upheaval into smooth progression. Epidemiol Psychiatr Sci 2020; 29: e87.