ApproAches to treAtment

The transition into adult carehelen Bruce

navina evans

Abstractthe authors have previously referred to the transition into adult mental

health services from child and adolescent services as ‘mind the gap’. In

this article they discuss the reasons for this gap and potential ways of

avoiding it. they then consider a few of the most common child and

adolescent disorders where the gap is significant, and include case ex-

amples, suggestions and ‘policies’ that may help reduce the discontinui-

ties. Finally, they suggest the way forward with joint educational teach-

ing across our training schemes ‘from cradle to grave’, to break down

the interfaces between our services for the future and to ‘demystify’ the

differences between us.

Keywords adolescence; mental health services; transition into adult

care

Introduction

There is considerable variation across the country in how well the transition between adult mental health services (AMHS) and child and adolescent mental health services (CAMHS) is man-aged. Within the UK, there is no agreement on how service boundaries are managed. Despite recent government guidelines for CAMHS in Every Child Matters1 that the cut-off age for ser-vices should be 18 years, there is considerable variation up and down the country with regard to this age. Some CAMHS still take young people only up to the end of year 11 at school (after GSCEs) or to their 17th birthday. In 1999, the Audit Commis-sion highlighted the relatively poor development of adolescent services and their inadequate links with other agencies, includ-ing adult mental services.2 The present authors suggest that the development of adolescent services has largely improved but that the links remain inadequate. This is especially significant as adolescence is a risk period for the emergence of serious mental illness such as schizophrenia.3

Helen Bruce FRCPsych is Consultant Child and Adolescent Psychiatrist

at East London NHS Foundation Trust and is Honorary Clinical Senior

Lecturer at Barts and the London School of Medicine and Dentistry,

London. Conflicts of interest: none declared.

Navina Evans MRCPscyh is a Consultant Child and Adolescent Psychiatrist

working in a Tier Four Specialist Adolescent Service in East London.

She is also Clinical Director for CAMHS in the East London Foundation

NHS Trust. Conflicts of interest: none declared.

psYchIAtrY 7:9 399

A Health Select Committee Report in 2000 on mental health services within the National Health Service identified several problems in the transition period.4 These included the failure of services to work together, the need for care management/­planning led by a single practitioner or key worker who coor-dinates care across all the relevant agencies, the shortage of in-patient services for adolescents, the need for early interven-tion, and poor liaison between the various agencies. A review of continuity in transition highlighted the paucity of high-quality research in this area.5

What are the barriers at the interface?

A previous paper by the authors6 involved a detailed exploration of how the interface between services has been influenced and how the services differ in conceptualizing and managing mental illnesses.3 This discussion is equally applicable to the develop-mental disorders such as attention deficit hyperactivity disorder (ADHD) and the autistic spectrum disorders. The barriers are summarized in Table 1.

Concerning evolution of services, AMHS have evolved under the successive influences of neurology, phenomenology, psy-chology, and sociology. Treatment strategies in AMHS were once entirely hospital based, but are now provided largely in commu-nity settings. The individual patient is usually the centre of such services. Child psychiatry emerged later as a discipline and in a more sociological context, gradually encompassing developmen-tal concerns and the systems theory models, including the role of the family and education. Biological psychiatry remains in its infancy and there is a lack of a strong evidence base for CAMHS practitioners to use. Use of the care programme approach (CPA), care coordination, and risk management is unfamiliar to many CAMHS clinicians. The focus in CAMHS is therefore on the inter-action between developmental and emotional processes, family, and social experiences.

The differing perspectives all collide at the interface exempli-fied in Case example 1. It is the lack of a specific diagnosis that is often a barrier to entry into adult services, and the young person in this case did not meet the criterion of entry of having ‘a severe enduring mental illness’. Young people negotiating the develop-mental tasks of adolescence, which include sexuality, career, and independent living, are often caught between two very different services, one of which considers them and their problems in a systematic family context and the other that considers them adult and autonomous.

Barriers at the interface between child/adolescent and adult mental health services

• evolution of services

• Differing perspectives

• Diagnostic uncertainty

• rigidity of boundaries

• Availability of services

• Lack of a common language

Table 1

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ApproAches to treAtment

Concerns about confidentially may also prevent adult services from involving the family, unless the young person gives clear consent to this. Families often find themselves largely excluded from care planning in adult services.

There is often a diagnostic uncertainty caused by overlap between the normal turmoil of adolescence and the non-specific prodrome of serious mental illness. This is often further compli-cated by frequent drug misuse. This, again, is a powerful inter-face barrier.

Rigid boundaries between CAMHS and AMHS often have clear disadvantages. The developmental point at which a young per-son becomes an adult is almost impossible to define and a rigid age cut-off can be unhelpful rather than facilitative for services striving to meet a young person’s needs appropriately.

Availability of services is also an issue. Traditionally, CAMHS have more provision for individual therapies and family thera-pies, which may form the main focus of the intervention in many cases. Access to local inpatient and day patient facilities is often more limited. The converse is true of adult services. In the authors’ experience, this has often led to an abrupt discontinuity when a young person who has been in individual psychotherapy, often for several years as in Case Study 1, is transferred to adult services where access to non-pharmacological services and psy-chotherapy is much more limited.

Available services fail even to share a common language. Our colleagues in adult services are often mystified by what we mean by Tiers 1, 2, 3, and 4, which form the main structures for CAMHS service delivery. Likewise, those working in CAMHS may struggle to understand what is meant by some adult terms, such as standard and enhanced CPA.

Behavioural problems

s is a 17-year-old boy with a long history of behavioural

problems that have been complicated by an early history

characterized by domestic violence and family breakdown. he

has been in contact with child and adolescent mental health

services (cAmhs) since the age of 6 years, when he was first

excluded from school for disruptive behaviour.

over the past 11 years, s and his family have had a

considerable amount of input from cAmhs, including individual

psychotherapy and family therapy alongside behavioural

interventions and parenting work. this was complemented by

school liaison throughout his educational career.

s’s 18th birthday was approaching and, although managing

to hold down a place at the local college where he was

completing a plumbing course, his behaviour remained a

concern, especially at times of stress.

After discussion, it was considered that s was not

appropriate for adult services as he did not have a mental

health diagnosis.

s eventually presented to adult services via the accident and

emergency department, having taken an overdose, but he was

quickly discharged.

Case study 1

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Conditions that cause issues at the interface (Table 2)

The developmental disordersCAMHS focus much of their resources on helping young people with developmental disorders achieve optimal function and on helping their families to come to terms with, and cope with, their disabilities. CAMHS have the responsibility for diagnosing their disorders initially and managing the interfaces with education and social services, often working in a joint way to provide the young person with the best life chances.

Autistic spectrum disordersIn the authors’ experience, the scenario described in Case study 2 is not uncommon. It is very unclear where young people with high-functioning autism ‘fit’ in adult services. They are often said to be ‘too intelligent’ to meet the criteria, which are often IQ based, for learning disability services, but not appropriate for ‘adult services’. After often intensive input from CAMHS and education services, they fall into a discontinuous gap in services at a time when they most need help to come to terms with leav-ing the structure of education and the family to the relatively unstructured adult life of independence, work or college, and adult relationships. Gradually, some services are being developed to bridge this gap with specialist posts, but they are as yet rare.

Attention deficit hyperactivity disorderMost CAMHS clinicians report that it is difficult to transfer a young person who is receiving pharmacotherapy for ADHD to AMHS. Fortunately, only a small proportion of adolescents will require ongoing pharmacotherapy, but, when they do, ongoing treatment services are difficult to locate. Even if an individual consultant will provide medication and medication review, other non-pharmacological treatments as recommended in the National Institute for Health and Clinical Excellence guidelines, such as work on behaviour, are virtually impossible to access in adult services.

It is equally problematic to find services to access and treat a parent who realizes through their child’s diagnostic pathway that they themselves have ADHD.

Learning disabilitiesThe therapeutic needs of young people with learning disabili-ties and their families are within the CAMHS remit. It has been the authors’ experience that, for children and young people with learning difficulties, service transitions can be smoother as the ethos of learning disability services and their treatment models

Conditions that cause issues at the interface

• Developmental disorders including:

○ Autistic spectrum disorder

○ Attention deficit hyperactivity disorder

• conduct disorders

• Learning disability and specific learning difficulties

• early-onset psychosis

• needs of looked-after children

Table 2

0 © 2008 published by elsevier Ltd.

ApproAches to treAtment

are more similar to those of CAMHS. Careful CPA planning with robust and early transition planning is essential.

Early-onset psychosisSince the implementation of early intervention services, the tran-sition for patients with first-episode psychosis has improved. Many Trusts have protocols in place to manage the process. However, in practice, many clinicians still report experiencing problems; many of the conditions outlined in Case study 3 seem to apply in the ‘real world’.

The difficulties experienced in this case demonstrate some of the procedural barriers that prevent smooth transition. The needs of the patient can be lost in system issues. Transition is often a traumatic experience; young people and their families are anxious about losing the support of a team they are familiar with and starting in a very different system. Adult services have a lot to offer these young people in terms of support and opportuni-ties. There is a danger that the experience of beginning a new relationship with adult services is a negative one, which causes problems for future engagement.

Other serious mental health problemsYoung people present to CAMHS with serious disorders such as obsessive–compulsive disorder, post-traumatic stress disorder, substance misuse, conduct disorder, emerging personality disor-der, anxiety disorder, and deliberate self-harm. These problems can seriously affect their ability to function and their develop-ment, and may have a serious impact on the family and the close network. CAMHS often adopt a multi-agency, psychosocial model for management. These young people can function with

Asperger’s syndrome

D is an 18-year-old male who was first diagnosed as having

Asperger’s syndrome at the age of 7 years by the local child and

adolescent mental health services (cAmhs). D continued to have

marked problems in social communication throughout childhood

and adolescence, with particular difficulties around puberty

with emerging sexuality. Despite preferring his own company, D

managed to survive through mainstream schooling and showed

a remarkable aptitude for maths. he achieved eight good Gcses

and three ‘A’ levels at grade A in maths, further maths, and

computing. D has just re-presented to the services, being unable

to manage the required social interactions at university, leaving

him depressed and isolated.

D received input throughout his childhood from cAmhs,

working closely with partner services in education. he has had

individual psychotherapy and family work to help the family

manage some of his odd behaviours and interactions, and to

look at reducing the impact of these on family relationships. As

he had done so well, it was decided not to transfer D to adult

services.

Despite his recent depressive episode, D still does not meet

the criteria to allow access to adult services, and services were

unclear whether he should fall under ‘learning disability’ or

mainstream adult services.

Case study 2

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some stability. It is often the case that, at transition, they do not meet the threshold for AMHS support or that the psychosocial interventions are not readily available.

Ways to break down the barriers

How can the barriers between services be broken down, and how can the interface best be managed? The authors suggest that several strategies may be considered depending upon local needs and priorities (Table 3).

Conclusion

Over the past few years much work has been done in improv-ing pathways for young people into adult care. However, all

Psychosis

J is 18 years old. she experienced her first psychotic illness,

which was associated with cannabis use, when she was aged 15

years. there was a background of physical abuse and domestic

violence. J was socially excluded and out of education.

J had an admission to hospital. engagement with child and

adolescent mental health services (cAmhs) was poor, although

her mother maintained good contact. there were two episodes

of relapse, which were managed in the community, and an

episode of hypomania. By the time she was 18 years, J was

relatively stable on a mood stabilizer and low-dose atypical

antipsychotic drug.

however, many social problems remained, J was not engaged

in education, and was beginning to self-harm, showing some

features that could be described as borderline personality

disorder.

transition to adult services proved to be much more difficult

than expected. there was disagreement between clinicians

about the accuracy of the diagnosis. cAmhs was also not

implementing a care programme approach (cpA) at the time.

this caused a barrier to transition as the handover information

could not be presented in a form that was understandable to

the community mental health team (cmht).

the eIps could not get involved because J did not meet the

criteria for their services.

transition could not take place until a handover cpA took

place, and this could not be set up as cAmhs did not practise

cpA and a care coordinator in the cmht had not been allocated.

the cmht also suggested a period of joint working, but this was

not possible as they did not allocate a care coordinator.

J became increasingly depressed about this situation and

started to express suicidal ideas; the cmht then stated that she

could not be transferred until she had improved. By this time,

J had already turned 18; she needed admission to manage the

crisis, but a bed could not be identified because she was no

longer suitable for admission to an adolescent unit but was not

known to any adult team.

the transition finally occurred about 6 months after J turned

18, requiring the involvement of senior management.

Case study 3

1 © 2008 published by elsevier Ltd.

ApproAches to treAtment

concerned need to continue to ‘Mind the gap’ between services; hopefully, this gap can be reduced by clearer transition proto-cols, greater understanding of each other’s services, and condi-tions that require transition, joint training, and joint working.

Foundation Trusts and Mental Health Trusts could identify this as an important issue that should be addressed by commit-ting to a Young People’s Strategy, set up to consider many issues, one of which would be transition. ◆

REfEREnCEs

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2 Audit commission. children in mind. London: Audit commission,

1999.

Ways to break down barriers between child/adolescent and adult mental health services

• specialist services for young people aged 16–25 years

• Liaison models

• Joint working

• specialist workers astride both services

• clear protocols and guidelines for transition

• Joint training

• research into interface issues

Table 3

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© 2008 published by elsevier Ltd.