At a glance 51: Mental health service transitions for young people
Published: November 2011
- Adolescence is a period of intense change for young people and a time when mental health problems may emerge or become more severe.
- It is important that young people understand and are given information about their mental health problems. Staff should be able to offer information about treatment and support options.
- The transition from child to adult mental health services should take into account the young person’s whole life, including their family, friends, housing, school, college, and work. Services need to be age-appropriate and flexible.
- It is vital that young people fully participate in planning their transition. Planning should start at least six months in advance
- Staff need to work collaboratively with other services (health, social care and voluntary services) in order to support young people throughout the transition process.
- Young people need access to a consistent, pro-active key worker and peer support from other young people.
- It is important to consider the needs of groups who may have particular difficulty accessing transition services.
- Managers should commission training for staff on use of the Child Assessment Framework and Care Planning Approach and monitor service performance.
Adolescence is a period of intense change for young people. It is also the time when new mental health problems such as psychosis or eating disorders may first emerge, or existing problems may become more complex or severe. This At a glance briefing outlines good practice for staff working with young people with mental health problems who may need to move from one service to another, that is, to make a ‘transition’. It will be of particular use for frontline staff, managers and commissioners providing services to young people aged 16-18 years who may need to make the transition from child and adolescent mental health services (CAMHS) to adult mental health services (AMHS) or other services for young people and adults. The messages are a summary of SCIE Guide 44: Mental health service transitions for young people.
Despite some promising and innovative practice, there is evidence that young people often struggle to transfer to new services.
Despite some promising and innovative practice, there is evidence that young people often struggle to transfer to new services, and in particular, are poorly supported when they are referred by CAMHS to AMHS. In February 2011, the Government published a mental health outcomes strategy, No health without mental health, which states that service transition from CAMHS to adult services can be improved by planning early, listening to young people, providing appropriate and accessible information to young people, and focusing on outcomes and joint commissioning.
CAMHS is made up of targeted, specialist services for children and adolescents. This includes primary care (e.g. GPs, school nurses and child health), along with other services based in non-health sectors, such as youth offending teams, behaviour and education support teams, pupil referral units, looked-after children’s services, and secure and other residential settings.
Young people using CAMHS have a range of psychological, emotional or behavioural problems; such as early psychosis, clinical depression, emerging personality disorders, eating disorders, Attention Deficit Hyperactivity Disorder (ADHD) and Autistic Spectrum Disorder (ASD). Problems with self-harm and alcohol and drug misuse are also common and rates of substance misuse are especially high. Often, young people also have more than one problem - referred to as ‘co-morbidity’.
Specialist CAMHS teams – sometimes called Tier 3 – are multi-disciplinary community-based teams made up of child and adolescent psychiatrists, psychologists, social workers, mental health nurses and other mental health specialists. These teams work with children and young people with (often complex), diagnosable mental health problems up until the age of 18 and are one of the main referral points for young people who need to make a transition to adult mental health services.
Voluntary sector services are important providers of mental health support to young people - for example, Youth Information Advice Counselling and Support services (YIACS) provide a wide range of counselling interventions and often work in partnership with both CAMHS and AMHS to support young people with different psychological and emotional problems.
Voluntary sector services are important providers of mental health support to young people.
Discharge from CAMHS and a potential move to AMHS takes place at varying ages, but most commonly when young people are aged between 16 and 18. However, transitions from children’s to adults’ services differ between sectors:
- children’s services are generally provided up to the age of 19
- the youth justice system works with children and young people aged between 10 and 17
- children who are looked after can continue to receive services until the age of 21, or 25 if they are in education
- age boundaries can also vary if a young person has a learning disability.
Barriers to effective transitions
The mental health needs of this diverse group are distinct from those of both children and adults. The way in which CAMHS and AMHS are organised does not always fit easily with the ways in which mental health problems are experienced by young people.
A young person may find him or herself without a service due to:
- differences in referral criteria and entry thresholds in CAMHS and AMHS
- inconsistencies in age cut-off points with some services ending when a young person is 16 whilst other services have a lower age limit of 18.
Young people with learning disabilities, ADHD, and Autistic Spectrum Disorder who receive help from CAMHS are likely to need ongoing support as adults. However, there are often a lack of adult services to cater for them.
Even when young people are successfully referred to adult services, the move may not go well. Practice is frequently inconsistent or poor. Problems include:
- poor understanding of young people’s mental health problems and how resilience can be developed
- administrative and legal processes, including service thresholds, which make services inflexible and unresponsive
- ‘unacceptable’ variations in the level and type of services available in different areas.
Making services accessible, acceptable, and easy to use is very important for young people and their families.
What makes services accessible and effective?
Making services accessible, acceptable, and easy to use is very important for young people and their families, particularly at transition. Generally young people think that moving to adult services is confusing and difficult to negotiate. As a result they may disengage from services even though they have continuing mental health needs. This can worsen their emotional and physical health, sometimes requiring sustained intensive or specialist treatment later on in a crisis; including admission to an inpatient unit, which can disrupt education or training. It can also have serious consequences for families, friends and communities.
The following principles have been shown to improve mental health service transitions:
1. Involving young people and their families in service design
Listening to young people and involving them in planning, developing, commissioning and providing services can produce significant improvements in service provision.
2. Providing information about support
It’s important to provide information about the transition process, and the services and support available, including from health and social care and voluntary sector services. Providing information is essential to enable the full, informed participation of young people in the transitions process. Young people need accessible and comprehensive information about their mental health problems, including treatment choices and self-help options. Many do not really understand what is meant by mental health problems or disorders, and fear the stigma of needing mental health services.
Young people value information which:
- is given both verbally and ‘reinforced’ in writing
- is attractive and jargon-free
- is culturally and age appropriate and relevant
- prepares them and their families for transition
- provides signposting from one service to another.
3. Providing holistic services
Young people want to be considered as people, not as a bundle of problems. Staff should consider the young person’s mental health needs in the context of their life and experiences: family, networks, friends, housing, interests, education and training or work. Because young people are growing and changing, they will have a wide variety of life events and needs to be considered, all of which may affect mental health.
Young people have lots of problems and it’s easier for them to walk into a place that deals with young people... it’s good to come to just one place where they sort everything out …Young person
4.Welcoming, approachable and flexible services
Staff in all services must be able to relate to young people and make them feel at ease. They need expertise and skills in engaging with young people and understanding the issues and concerns that affect them.
Young people want:
- informal approaches and to be made welcome
- to be able to trust staff and to be listened to
- to feel supported and not pressurised
- continuity of staff wherever possible – so as not to have to keep ‘re-telling our stories’
- (where appropriate) community-based and non-health services
- flexible services that can be stepped up and down according to need and are accessible easily and quickly, from home, out of hours and at weekends.
No matter what the problem was they would help me. I’ve been seeing the same professionals since I was 15.Young person
Access for seldom heard and vulnerable groups
Socially excluded young people who need mental health services may be hidden and find it difficult to get support. Some may have a disrupted history of accessing services, and encounter stigma, racism and language difficulties. These young people may need more intensive support to avoid falling through the net.
Young people who may encounter particular difficulties accessing services, or support during transition, include those who are not in education, training or employment (NEET), looked after young people or care leavers, young people who are refugees or asylum seekers, young people from traveller communities and those who live in isolated rural areas.
Poverty in rural areas, combined with limited public transport, can limit young people’s access to mental health provision and support. For some groups, problems accessing services are recognised and specialist teams provide support by offering outreach and satellite services and developing telephone and internet-based sources of information and advice.
Young people who are in hospital, whether an adolescent CAMHS unit, or an adult ward, are also at risk, because they may be placed away from their local area and have infrequent contact with their CAMHS coordinator. A particular problem can arise if a young person passes their eighteenth birthday (i.e. the transition boundary from CAMHS) in hospital. The lack of involvement of young people themselves in their care and discharge planning when they are inpatients is a significant problem.
Example: Continuity of care
Camden and Islington Early Intervention Service (EIS) demonstrated age-appropriate services and continuity of care in the case of a 16 year old girl admitted to an adolescent inpatient unit where she was diagnosed with bipolar affective disorder. The EIS CAMHS team kept a close eye on her, were aware of her discharge plans, and were able to implement these post-discharge. Once she was 18, the crisis team was brought in to work alongside EIS to provide intensive home treatment and to improve her compliance with taking her medication. She was admitted to an adult ward where again the EIS CAMHS team remained involved with her care to give a CAMHS perspective. She was discharged after a few weeks, again to the EIS CAMHS team, and now has positive outcomes in terms of mental health, college and relationships.
Planning and practice in transition
Transition is a process, requiring:
- an early start (assessment of needs)
- a discharge from CAMHS and possibly a transfer to AMHS or other secondary adult services
- a transition plan for continuity of support into adulthood, and for early intervention if greater need arises
- follow up of outcomes.
The TRACK study defines the best transition services as those which feature:
- effective information transfer between services (e.g. referral letters and case notes), and written information for the young person
- a period of parallel care and joint working between CAMHS and AMHS or other services
- transition planning with at least one meeting including the young person, parent/carer, CAMHS, AMHS and other services
- continuity of care (from AMHS or elsewhere) at least three months after transition.
Working collaboratively with other professionals and agencies is vital for effective transitions. Staff should know how each other’s services operate in order to provide coordinated and joined up care and support.
Local interagency training can help to share practice knowledge, facilitate discussion, solve problems and promote networking. If joint protocols are in place, these should form the basis for joint training. Lead professionals in non-health sectors may not be aware of protocols in the health service or of their role in service transition.
Other links could be created via establishing local professional networks to share good practice and joint learning. CAMHS could also consider providing an ongoing consultancy and liaison role to AMHS and non-specialist adult services, on how to work with and listen to young people, and implement an holistic approach.
It is also important that services have compatible IT systems so that they can easily share and access information.
Example: Multi-disciplinary services
The Rivendell Unit in Wakefield has a multidisciplinary transition service for 17 year old women. This designated unit is within a large (adult) female prison for very vulnerable young women with high rates of self harm and complex psychopathology. The young people are transferred on their eighteenth birthday to the main prison site, with one or two transfers each month. The young women were involved early on in the design of the new service through a focus group. They said that getting advice during transition was a key need. They emphasised the importance of having someone to talk to, of health professionals gaining their trust and maintaining confidentiality, and having practical support such as filling out forms. The main benefit of the new service is that it facilitates communication between the young person, the Forensic CAMHS team and the AMHS team well before the actual transfer is due. This reduces the anxieties of the young person and of the system.
Performance management, monitoring and evaluation
National health policy and guidance emphasises the need for all services to monitor their performance. A variety of outcome frameworks and national-level indicators have been developed to support this. With regard to young people in contact with mental health services, there are a number of assessment processes, planning systems and quality criteria that can be used to audit and evaluate service performance and staff practices, including:
- The Common Assessment Framework (CAF) and the Framework for the Assessment of Children in Need and their Families
- The Care Programme Approach (CPA)
- The You’re welcome quality criteria for young people friendly health services (DH 2011).
It is important to:
- build and implement audit and review systems and routine monitoring indicators, and provide training to staff on what data needs to be collected
- use national level indicators or targets where relevant and/or feasible
- factor the voice of the young people and parents/carers into routine monitoring indicators
- monitor young people’s outcomes, including those who don’t go to AMHS, to capture whether needs and resources were matched and to uncover unmet needs
- SCIE: Research briefing 37: Mental health service transitions for young people
- SCIE Guide 44: Mental health service transitions for young people
- Department of Health: No health without mental health
- Department of Health: Care Programme Approach
- Department of Health: You’re welcome quality criteria
- Common Assessment Framework
- Singh, S.P. et al. (2008) Transitions of care from child and adolescent mental health services to adult mental health services (TRACK study): a study of protocols in Greater London, BMC Health Services Research, no 8