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Written by Dr Kuben Naidoo, MD, Consultant Psychiatrist, Clinical Director Sefton and Kirby, Mersey Care NHS Foundation Trust, UK

In the UK, Child and Adolescent Mental Health Services (CAMHS) and paediatric services manage children aged 16 years and under.1 The expectation is that adult Community Mental Health Teams (CMHTs) will assume responsibility for these individuals when they reach 16 years of age.1 However, there is regional variation, with some services agreeing to ‘hold on’ to patients until they reach 18 years of age.1

Dr Naidoo: “In principle, the transition between CAMHS and CMHTs should be an easy and seamless process, which causes minimum disruption to the patient and their family. In practice, despite the best efforts of CAMHS and CMHTs, the process is cumbersome and often laden with bureaucratic burden.”

What do the guidelines suggest?

The National Institute for Health and Care Excellence (NICE) Guideline on the diagnosis and management of ADHD (NG87) recommends that:2

  • A young person with ADHD under the care of CAMHS or paediatric services should be re-assessed at school-leaving age for the need to continue with treatment under adult mental health services (AMHS). NICE recommends that the transition should be completed by the time the patient is 18 years of age.2

In what way can transition vary between patients?

In my clinical practice, I see two types of patient transitioning to AMHS:

  • The first group will be the patients with ADHD and no comorbid psychiatric conditions. These are the cases that we most often receive from paediatric teams.
  • The second group will be patients who have ADHD along with a psychiatric comorbidity.
    • Approximately 50% of adults with ADHD will have a comorbid psychiatric condition, with the most common being anxiety disorders followed by mood disorders.3

The patients with ADHD and no comorbid psychiatric conditions that I see are unfortunately at a disadvantage, due to the lack of resources available nationally for adult ADHD services.4 In my own clinical experience, I have personally observed capped services and insufficient funding by Clinical Commissioning Groups to expand ADHD services and improve access to treatment. In my experience, waiting lists can include several hundreds of patients, and it can be years before referred patients are seen by ADHD services. As a result, patients are often lost to follow-up and are therefore unlikely to receive any treatment for their ADHD symptoms.4 Subsequently, I sometimes see these patients struggling to cope at college or in employment, and the costs of untreated ADHD have been highlighted.5

Dr Naidoo: “The transition between child and adult services is a critical period of development, particularly where occupational and academic success are concerned.”

In my local service, the group of patients with ADHD alone are disadvantaged in terms of access to adult ADHD services:

  • Shared care is being rolled out in certain areas, and some general practitioners (GPs) are now taking on prescribing for patients with ADHD.6
  • However, ADHD services are still required to retain patients on their caseload, so routine reviews are still necessary, creating a bottleneck in the system and preventing acceptance of new referrals due to the limited clinical resources in these teams.
  • There is some innovative work taking place on the Wirral (Merseyside, UK) to address this by identifying GPs with a special interest in ADHD, who will take on the follow-up after patients have been treated and stabilised by the ADHD specialist team.

In my experience, the process for individuals with ADHD and comorbid psychiatric conditions is often much easier:

  • A referral is made to the CMHT and a care coordinator will be allocated.
  • In my area, a Care Programme Approach meeting will be arranged, where the transition can be formalised.
    • This should usually take place within 6 weeks of the time of referral to the adult service, but will of course depend on the age of the patient at the time of referral.
  • Our local service ensures that following this meeting, the new team will be in a position to consider continued treatment for ADHD along with the comorbid psychiatric condition.

I have observed some examples of good collaboration with existing ADHD services, where the CMHT consultant continues treatment for ADHD and the ADHD specialist provides oversight, and it would be my recommendation that this model should be expanded to all areas of the country.4

What processes are in place in my area that support a good transition between services?

Dr Naidoo: “In my experience, the first step is to identify those patients with ADHD who will soon be transitioning to AMHS and ensure that they are educated about their condition and are made aware of the need to remain on treatment. It is my opinion that a close working relationship with the carer/s is also important at this stage.
  • Ownership of the process is essential, and for this reason, a named person (care coordinator) is identified in the CAMHS team who will oversee the transfer to AMHS.
    • The care coordinator will liaise with the relevant CMHT (this could even be a year in advance) to ensure that the receiving team is made aware of the referral and that relevant information (risk assessments, clinical documentation and psychological assessments) can be shared. Collaboration is key.
  • The receiving team will then also identify a care coordinator who will liaise with the patient prior to the initial appointment with AMHS.
    • This is helpful in explaining the process of transition and how AMHS work (which may differ from the input the patient received in CAMHS).
    • Moving to a different service can be very daunting for the patients I see, irrespective of age, and I think it is important to consider how long a patient may take to adapt to this change to the extent that they are comfortable to share information and raise concerns with the new treating team.
    • I also find it helpful to identify any comorbid psychiatric conditions that need addressing (e.g. depression, anxiety or emerging personality disorders).
  • The transfer-of-care meeting should be attended by the patient and their carer/s, as well as the CAMHS care coordinator. In my experience, it is helpful if the CAMHS consultant can attend as well, but this is not always practical and may potentially delay the process of transition if there is an attempt to get more individuals to attend.
  • Once the transfer of care to AMHS is completed and an initial assessment has taken place, CAMHS will withdraw their involvement and AMHS will work towards stabilising the ADHD symptoms in the short term and addressing any psychiatric comorbidity.
  • Shared-care protocols are being developed between specialist services and primary care.6,7 Stable patients will eventually be transferred to the care of their GP with a shared-care protocol in place.6,7 It is essential that the patient will have ready access to specialist services at point.7 Examples of scenarios where I would recommend that patients are referred back to specialist services would include observation of any deterioration in the patient’s mental state or if the patient wishes to have their medication reviewed.
Dr Naidoo: “Despite transition to AMHS being a key milestone for individuals with ADHD, we are still far from achieving optimal processes in practice. Action is needed to identify and address gaps in service provision and to define a standard of care to be provided nationally. There is a need to raise awareness of ADHD amongst GPs, to promote collaboration between services and to increase the number of professionals who can manage ADHD both in CAMHS and AMHS settings.”

 


Disclaimer: The views expressed here are the views of the physician and based upon his own personal clinical experience. They are not those of Shire.

  1. National Health Service. Child and adolescent mental health services (CAMHS). Available at: https://www.nhs.uk/using-the-nhs/nhs-services/mental-health-services/child-and-adolescent-mental-health-services-camhs/. Last updated April 2016. Last accessed October 2018.
  2. NICE guideline 2018. Attention deficit hyperactivity disorder: diagnosis and management. Available at: nice.org.uk/guidance/ng87. Last accessed October 2018.
  3. Fayyad J, Sampson NA, Hwang I, et al. The descriptive epidemiology of DSM-IV Adult ADHD in the World Health Organization World Mental Health Surveys. Atten Defic Hyperact Disord 2017; 9: 47-65.
  4. Joint Commissioning Panel for Mental Health. Guidance for commissioners of mental health services for young people making the transition from child and adolescent to adult services. Available at: https://www.rcpsych.ac.uk/pdf/JCP-MH%20CAMHS%20transitions%20(March%202012).pdf. Last updated February 2012. Last accessed October 2018.
  5. Vibert S. Your attention please: the social and economic burden of ADHD (Supported by Shire). Available at: https://www.demos.co.uk/wp-content/uploads/2018/02/Your-Attention-Please-the-social-and-economic-impact-of-ADHD-.pdf. Last updated February 2018. Last accessed October 2018.
  6. Wirral Medicines Management. Shared Care. Available at: http://mm.wirral.nhs.uk/sharedcare/. Last accessed October 2018.
  7. Cheshire and Wirral Partnership. Shared Care Guidelines: Lisdexamfetamine for adult ADHD. Available at: http://mm.wirral.nhs.uk/document_uploads/guidelines/Approved-LisdexamfetamineinAdults21-11-16.pdf. Last updated November 2016. Last accessed October 2018.
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