The UK National Institute for Health and Care Excellence (NICE) clinical guidelines contain recommendations for transition of child to adult services for adolescents with ADHD (NICE guidelines, 2016). This study assessed the views of clinicians working in both child and adult services for ADHD regarding the processes and procedures for transition between services based on the use of NICE guidelines.
Clinicians notified the British Paediatric Surveillance Unit and the Child and Adolescent Psychiatry Surveillance System when an adolescent with ADHD taking pharmacotherapy was within 6 months of the transition age boundary. For each eligible adolescent, a baseline notification questionnaire prior to transitioning and a follow-up questionnaire 9 months later was sent to the reporting clinician.* Some clinicians working in child or adult services were also selected for a telephone interview.†
In total, 315 baseline (n = 202 from paediatricians; n = 113 from psychiatrists) and 247 follow-up (n = 161 from paediatricians; n = 86 from psychiatrists) questionnaires were received. At baseline, 172 (55%) clinicians stated that their local trust had a transition protocol and this was used by 148 (86%) of them. At follow-up, 158 (64%) clinicians indicated that their transition referral had been accepted; 75 (30%) had received feedback from the adult service about the transition and 55 (35%) indicated that their patient had attended the first appointment in the adult service, and thus had successfully transitioned. More patients referred from psychiatry (n = 33 [45%]) had successfully transitioned compared with paediatrics (n = 22 [26%]). At baseline and follow-up, the majority of clinicians noted information sharing (84.6% and 68.8%, respectively) and adolescent/carer involvement (81.4% and 69.6%, respectively) in the transition process; however, fewer clinicians had a joint planning meeting between services (16.3% and 10.5%, respectively). Only 19.8% and 30.8% of clinicians reported consistency of care and continuity of care, respectively.
Overall, 38 clinicians (n = 22 from child services; n = 16 from adult services) across the UK (92% from England) with extensive current or previous knowledge of ADHD services were interviewed. Clinicians were mostly female (24:14 female to male ratio) and were either consultant paediatricians (n = 15), consultant psychiatrists (n = 19) or from other health disciplines e.g. mental health nurse or ADHD practitioner (n = 4). Most clinicians from child and adult services were aware of NICE guidelines but knowledge of specific transition recommendations were mixed. Clinicians from adult services were more likely to follow NICE guidelines, whereas those from child services felt that the guidelines are not specific enough or highly valued but do try to follow them regardless. There were mixed views from clinicians from both services on whether local guidelines or protocols were helpful, and many indicated that there were no local policies despite the NICE recommendations. The primary reason by clinicians for not following the NICE guidelines was workload and resources. Other examples included: lack of joint working between child and adult services; cultural differences between services; and clinicians’ and local commissioning attitudes to adult ADHD. Some clinicians recognised that the age of transition is a difficult time for adolescents with ADHD and may cause anxiety and low self-esteem. They recognised the need to communicate the transition process to adolescents with ADHD but acknowledged that their own uncertainties and other pressures could hinder this process.
The authors concluded that clinicians from child and adult services involved in the transition process of adolescents with ADHD may judge NICE guidelines to be unrealistic due to the current service configurations and the limited resources available. Therefore, more work may be required to close the gap between what is possible for clinicians and NICE guideline recommendations.
*Questionnaires used structured and open-text response boxes to record patient demographics, current pharmacotherapy, intended referral details, local transition protocols and procedures, and details regarding the transition process implemented by clinicians. ‘Yes’ or ‘no’ tick-boxes were used to confirm if the clinicians felt that each element of the transition process recommended by NICE had been adhered to
†Questions focused on the following themes: transition protocols and procedures; the Care Programme Approach; pharmacotherapy use; current contact with services; and experience of transition
Eke H, Janssens A, Newlove-Delgado T, et al. Clinician perspectives on the use of NICE guidelines for the process of transition in attention deficit hyperactivity disorder (ADHD). Clin Care Health Dev 2020; 46: 111-120.
NICE guideline 2016. Transition from children’s to adults’ services for young people using health or social care services. Available at: https://www.nice.org.uk/guidance/ng43. Accessed December 2019.