Concerning the availability of early adult mental health service provision, this study aimed to conduct a narrative case note analysis of the ADHD cohort from the iTRACK case note study of CAMHS-AMHS transitions in Ireland, with a focus on case characteristics and service transfer on reaching the CAMHS transition boundary.
Invitations to participate were sent to all 60 CAMHS services in Ireland, and 8 teams (13%) retrospectively identified a total of 62 young people approaching the service transitions boundary for data extraction. All 4 Health Service Executive regions were included: Dublin Mid-Leinster (n=40; 66%), Dublin North-East (n=1; 2%), South (n=18; 30%) and West (n=2; 3%), and 1 participant for which the case notes did not specify the region. By adapting the UK TRACK data extraction tool, the clinical teams/researchers were able to extract: 1) CAMHS diagnoses at initial presentation and transitions boundary, 2) clinical and socio-demographic information, 3) parent engagement, 4) details of the CAHMS clinician perception of AMHS referral suitability, and 5) details of referral and transfer/transition process. Current status, management plan and the reasons for non-referral to AMHS were extracted for those in CAMHS beyond the transitions boundary. Case files were categorised as referred to AMHS, not referred to AMHS, discharged to general practitioner (GP), referral refused by the young person and/or the parent, or disengaged.
A total of 20 young people with a diagnosis of ADHD at the transitions boundary were included in the iTRACK ADHD cohort (16 males and 4 females, all white Irish). The mean (SD) age at first referral was 11.6 (3.98) years for 16 participants. 3 subjects transitioned from CAMHS to AMHS at 16 years of age and for all others, at 18 years of age.
Of the 20 young people, 10 had 1 to 3 psychiatric comorbidities at the transitions boundary (autism spectrum disorder, n=4; learning difficulties, n=3; anxiety, n=2; depression, n=1; eating disorder, n=1; post-traumatic stress disorder, n=1; substance use disorder, n=1; reactive attachment disorder, n=1).
Analysis of the available case note information highlighted that:
- Of the 20 young people in the iTRACK ADHD cohort, none were referred to a public AMHS, 2 transitioned to a private AMHS, 1 referred to AMHS by GP was treated for 6 months, 8 were retained by CAMHS and 8 disengaged.
- Of the 10 young people in the iTRACK ADHD cohort with ≥1 psychiatric comorbidity, 2 were referred to a private AMHS, 2 were discharged to GP, 2 refused referrals, instead requesting a GP, 1 refused referral and disengaged and 3 disengaged pre-transitions boundary.
- Of 5 clinicians who did not make referrals despite perceiving that the patients had ongoing health needs, 3 believed that the referrals would not be accepted by AMHS and 2 that the AMHS did not have the service or expertise required to treat the participants.
Limitations of the study are that the recruited sample was small and heavily weighted towards the Dublin Mid-Leinster region, meaning that conclusions regarding regional variation in service outcomes cannot be drawn. The young people enrolled in the ADHD cohort were regarded as relatively stable, with living accommodation, in attendance of full-time education and with parents who regularly engaged with CAMHS, it is possible that this cohort does not represent the more vulnerable end of the ADHD spectrum. Finally, the CAMHS record-keeping on transition was poor, particularly for non-referrals and subsequent outcomes.
The authors conclude that the current study identifies a lack of transition to adult support services for young people with ADHD in Ireland, with a need for AMHS to increase ADHD knowledge and services available. There also exists an urgent need for understanding both young people and CAMHS clinicians’ negative perceptions of ADHD referrals.
CAMHS-AMHS, Child and Adolescent Mental Health Service-Adult Mental Health Service
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 2018; 12: 505-512.